
flass YrL v^-q, 
Book 

COPYRIGHT DEPOSIT. 



J176 



MEDICAL SCIENCE OF TO-DAY 




Sleeping Sickness Germs in the Blood of a Rat 



These are cinematograph pictures exhibited before a Medical Society, showing the 
movements and development of the mi;robe of sleeping sickness. The round bodies 
are the red corpuscles. 



MEDICAL SCIENCE 
OF TO-DAY 

A POPULAR ACCOUNT OF THE MORE 

RECENT DEVELOPMENTS IN 

MEDICINE & SURGERY 



By 
WILLMOTT EVANS, 

M.D., B.S., B.Sc. Lond., F.R.C.S. Eng. 

Surgeon to the Royal Free Hospital, and Surgeon to the 
Hospital for Diseases of the Skin, Blackfriars 



With Thirty-one Illustrations 



PHILADELPHIA 
J. B. LIPPINCOTT COMPANY 

LONDON : SEELEY, SERVICE & CO. LTD. 
1912 



R, 



4-q 



7- 



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PREFACE 

The object of this book is to give a simple explana- 
tion of some of the main principles on which are 
based the medicine and surgery of the present time. 
It has been written for non-medical readers, and the 
descriptions have been made as little technical as the 
case permits. I feel strongly that a wider acquaint- 
ance, on the part of the public, with the theories of 
the treatment of disease and injury will lead to a 
higher estimation of the value of medical science in 
the state. In the preparation of a book such as 
this I have necessarily been indebted to many works 
which I need not name, but I should like to mention 
my indebtedness to The Prevention of Malaria, by Sir 
Ronald Ross ; to Insects and Disease, by Professor 
Rennie W. Doane ; to The Death-dealing Insects and 
their Story, by C. Conyers Morrell ; and to Malaria, a 
neglected factor in the History of Greece and Rome, by 
W. H. S. Jones. 

I have also to thank Messrs. Longmans, Green and 
Co. for the use of Figs. 85 and 114 from The Essentials 
of Practical Bacteriology, by Mr. H. J. Curtis. 

WILLMOTT EVANS. 

Harley Street, 
London. 

ix 



CONTENTS 

CHAPTER I 

„ PAGE 

Introduction *F . .17 

CHAPTER II 
The Medicine of the Past 22 

CHAPTER III 
The Causes of Disease 29 

CHAPTER IV 
Germs 4° 

CHAPTER V 
The Microscope in Medicine 54 

CHAPTER VI 

The Microscope in Medicine (continued) ... 63 

CHAPTER VII 

The Microscope in Medicine {concluded) ... 73 

x 



Contents 

CHAPTER VIII 



PAGE 

Immunity 77 



CHAPTER IX 
Immunity {continued) 88 

CHAPTER X 
Vaccination 97 

CHAPTER XI 
Diagnosis 107 

CHAPTER XII 
The Story of the Discovery of Anesthesia . . 123 

CHAPTER XIII 
Antiseptic Surgery 136 

CHAPTER XIV 
The Arrest of Hemorrhage 151 

CHAPTER XV 
Shock 159 



CHAPTER XVI 

What Modern Surgery can do 164 

xi 



Contents 

CHAPTER XVII 

PAGE 

The Value of Drugs 179 

CHAPTER XVIII 
Organotherapy 190 

CHAPTER XIX 
Malaria 198 

CHAPTER XX 

The Political Importance of Malaria . . . 204 

CHAPTER XXI 

The R6le of Insects in the Production of Disease 213 

CHAPTER XXII 

The Role of Insects in the Production of Disease 

(continued) 224 

CHAPTER XXIII 

The Fight against Malaria 232 

CHAPTER XXIV 
Industrial Diseases 243 

CHAPTER XXV 

Industrial Diseases (continued) 251 

xii 



Contents 

CHAPTER XXVI 



PAGB 

Legal Medicine 258 



CHAPTER XXVII 
Legal Medicine {continued) 267 

CHAPTER XXVIII 
Idiosyncrasies 285 



CHAPTER XXIX 

Treatment by X-rays, by Radium, and by Finsen 

Light 292 



CHAPTER XXX 
Malingering 306 

CHAPTER XXXI 
The Medicine of the Future 313 

Index 321 



xin 



LIST OF ILLUSTRATIONS 



Sleeping Sickness Germs in the Blood of 
a Rat 



Gathering Mandragora .... 

An Operation on the Liver . 

Crystals from Human Blood 

„ „ the Blood of the Baboon 

„ „ „ „ Horse 

„ „ H „ Squirrel 

„ „ „ „ Goose 

„ „ „ „ Guinea Pig 



The Tsetse-Fly ..... 

Rat Flea 

Mosquito (Female) of Malaria 

An Amoeba 

A "Culture" of Diphtheria Bacilli 

An X-Ray Photograph of a Foreign 
Gullet of a Child . 

A Broken Knee-cap soon after the Injury 

„ „ united by Silver Wire 

A Non- Malarial Mosquito (Female) . 

(Male) 



Body in 



Mosquito (Male) of Malaria 

xiv 



Frontispiece 

PAGE 

xvi 

39 
60 
60 
62 
62 
64 
64 
78 
78 
78 
92 
92 

120 
177 
177 
200 
200 
200 



THE 



List of Illustrations 

FAGE 

Larva of Mosquito 218 

Mosquito Larvae 218 

Egg of Malarial Mosquito : Dorsal View . . . 220 

„ „ „ Side View . . . 220 

Mosquito Larvae 220 

Bacilli of Influenza 220 

Mosquito of Yellow Fever 226 

Foot of House-Fly 226 

Armed against the Plague in China .... 228 
A Safety Cabinet for X-Ray Operators . . .294 

Treatment by Radium 302 



XV 




yrom "An^thetiCB. Antient and Modern,- fc 7 pension of Burroughs Wellccoe ft Co, 
GATHERING MANDRAGORA 
From a MS. of the Thirteenth Century 
« T« nather ve mandracora, go forthe at dead of nyght, and take a dog 



MEDICAL SCIENCE OF 
TO-DAY 



CHAPTER I 

INTRODUCTION 

In the Science of Medicine the problems presenting 
themselves at the present time are, in one way, very 
similar to those which came up for solution in the 
early ages of civilisation, yet in another way they are 
very different. 

They are similar, for to-day we have, as they had in 
those bygone ages, to solve the problems of the origin, 
the diagnosis, and the treatment of disease. We have 
to find out why disease arises ; w r e have to discover 
how to recognise it when it has appeared, and having 
diagnosed it, to treat it as effectively as possible, so 
as to prevent loss of life or limb. We have solved 
many of the problems that baffled our predecessors ; 
we have tracked one disease after another to its 
origin ; yet even now, after centuries of research, there 
are many diseases whose cause we do not know, there 
are many morbid conditions which we cannot yet 
diagnose with correctness and certitude, and there are 
even more diseases which we cannot cure. Neverthe- 
less, all who have really considered the matter feel 

17 B 



Introduction 

confident that in time, with a persistence of that love 
for investigation and for the discovery of truth which 
characterises all true students of science, we shall 
know what is, as yet, unknown of these diseases, we 
shall have discovered the origin of each, and made its 
diagnosis and its treatment sure. 

On the other hand, the medical problems of the 
present day are different, for now we are anxious 
rather to prevent disease than to cure it when it has 
already appeared. Medical men all over the world 
are now aiming, not at the discovery merely of the 
causes of disease and of its treatment, but of the 
methods by which its occurrence may be prevented. 
Every year we are learning more and more how to 
control diseases in their origin. Sometimes we 
endeavour to prevent the cause itself obtaining access 
to the body. Typhoid fever almost always originates 
from contaminated water or milk, so we endeavour to 
take precautions that no contamination of the sources 
of supply shall occur, or if for any reason this pre- 
caution be impossible, we employ means later to 
render the water or milk innocuous. 

Sometimes the causes of disease are so widespread 
that they cannot be avoided, and then we may rind 
that the best method of preventing an attack of the 
disease is by so strengthening the natural resisting 
powers of the body that it will be able successfully 
to overcome the assaults of the cause of the disease 
Sometimes it is recognised that by improving the 
conditions of existence, by providing better ven 
tilation, healthier sites, and more suitable buildings 
we may ward off dangers that would otherwise 
assail us. 

How to carry out these objects completely and 



Introduction 

effectively has become the most important medical 
problem of our time. 

Similar attempts have no doubt been made in the 
past, but until recently the study of the causes of 
disease had not proved very fruitful, and therefore it 
was impossible for those who came before us to do 
what we, with our fuller knowledge of the causation 
of disease, are able to effect. 

If we recognise, as we must, the all-importance of 
the prevention of disease, we have to acknowledge 
that success in carrying out the preventive mea- 
sures which medical science has indicated does not 
depend only on the members of the medical pro- 
fession. It depends on the Government, on every 
voter in the kingdom, and on every individual citizen ; 
for without the co-operation of those who govern and 
those who are governed medical men can do nothing. 
Unless the country as a whole recognises the im- 
portance and the efficacy of the measures of preven- 
tion suggested, any attempts that may be made must 
fail. Sometimes by an active interference the passage 
of laws calculated to prevent disease will be hindered, 
but it is no less common for the apathy and mere 
inertia of the people to put insurmountable obstacles 
in the way of the progress of preventive medicine. 

Much of the opposition, active or passive, on the 
part of the general mass of the public is due merely 
to want of knowledge. When the interference is 
active, the instigators of it are misled by preconceived 
ideas of the nature of disease, of its cure, or of its 
prevention. When the opposition is passive it is 
because the opposers are ignorant of how much can 
be accomplished by well-directed efforts and how 
valuable those results may be. 

19 



Introduction 

No one knowingly exposes himself to dangers which 
are avoidable unless actuated by powerful motives. 
No one intentionally incurs unnecessary evils. If on 
the one hand the greatness of the risks that are run 
is fully realised, and on the other hand the ease with 
which those risks may be avoided is appreciated, none 
will oppose the measures needed for the prevention 
of disease. 

If we agree that the mainspring of the opposition 
to hygienic measures, whether that opposition is in- 
tentional or not, is lack of knowledge, it is clearly 
only reasonable that means should be taken to educate 
the public mind on some, at least, of the matters 
which are now engaging the attention of the medical 
profession, on some of the problems which we are 
now endeavouring to solve. If this is done, there 
will be a hope that at least some of the opposition 
which we now encounter will be removed. Though 
naturally legislators must be for the most part de- 
pendent on the expert opinions with which they are 
supplied, yet they would probably be more ready to 
accept those opinions if they were more able to ap- 
preciate the grounds on which those opinions were 
based. 

Moreover, if the members of the public were better 
acquainted with some of the facts of medical science, 
they would understand better than at present the 
marvellous intricacy of medicine and the difficulties 
that lie in the way of diagnosis ; they would be less 
prone to resort to quack medicines and to place their 
trust in treatment which must rest on their own 
diagnoses. They would be more tolerant of errors 
of diagnosis and treatment if they appreciated more 
fully how difficult diagnosis and treatment may be. 

20 



Introduction 

This book necessarily only contains a very small 
portion of the facts of the science of medicine. It 
endeavours to explain some of the more recent ad- 
vances in the various branches of medicine and surgery, 
and it is intended to show the need for measures of 
prevention, which are advised or adopted. It is 
hardly necessary to say that no attempt has been 
made to give anything like a general account of 
medical science ; that would have been of little use 
and in some ways possibly harmful ; but an acquaint- 
ance, slight though it may be, with the general prin- 
ciples on which the modern science of healing is 
based can, in my opinion, be productive only of 
good. 



21 




CHAPTER II 

THE MEDICINE OF THE PAST 

To be able to appreciate more fully the advanced 
position held by medical science to-day, it is well to 
know something of the medicine of the past. Not 
that we may condemn the medicine as practised in 
ages other than our own, for the doctors in the past 
strove, as do those of the present day, strenuously to 
make advances in their science, but rather that we 
may be better able to gauge the enormous progress 
which has been made within recent years. 

The origin of the medical art is involved in dense 
obscurity. The sciences of medicine and surgery as 
practised to-day are based, in part at least, on methods 
devised many thousands of years ago, which we know 
must have existed, not because we have any direct 
knowledge of them, but because we are led to deduce 
their existence from the traces they have left behind.- 
Even in the world of the present day we have many 
opportunities of seeing how in early stages of civilisa- 
tion the practice of medicine is pursued. Yet year by 
year it is becoming more difficult to find a savage race 
unaffected directly or indirectly by modern civilisation, 
and therefore it is becoming more difficult to discover 
a race where the habits and customs are purely those 
of uncivilised man. For, even in the least developed 
races still existing, many steps have been taken along 
the road which leads to civilisation, and therefore 

22 



The Medicine of the Past 

even in these we must not expect to find medicine 
and surgery at their earliest stage. Everywhere, even 
in these very savage races, we find a wide knowledge 
of the value of herbs and roots and other natural 
products in the treatment of disease and injury, and 
this acquaintance with the properties of plants and 
minerals must have required many years, or rather 
many centuries, to bring about. In these lowly de- 
veloped peoples the knowledge of the value of herbs 
is possessed by two sets of persons. Part of the 
knowledge resides in some of the older women of the 
tribe, who practise it in conjunction with nursing ; but 
more often still the medical art, such as it is, is asso- 
ciated with the priesthood. The " Medicine Man " of 
the tribe possesses a knowledge of the curative proper- 
ties of many substances, and this he utilises for the 
restoration to health of those who are inclined to 
support him. Unfortunately there is only too much 
likelihood that this knowledge of simples is combined 
with the knowledge of poisons, which are used to 
enhance the respect paid to his priestly office and to 
assist in the removal of those members of the tribe 
who are likely to be obnoxious to him. 

No small knowledge of surgery is often possessed 
by the " Medicine Man," and travellers have told 
wonderful tales of the operative dexterity of some 
of them, especially in Central Africa, but it is in 
dealing with wounds that the manipulative dexterity 
and medical knowledge of the " Medicine Man " are 
most conspicuously shown, and this is what might 
have been expected. In all early races war, whether 
defensive or offensive, is one of the most important 
occupations of the men of the community, and the 
rapid healing of wounds received in battle is of intense 

23 



The Medicine of the Past 

value in maintaining the fighting strength of the tribe. 
Hunting also is one of the most important occupations 
of savage races, and injuries received in the chase 
must often need treatment. 

The earliest knowledge that we possess of the 
practice of surgery amongst the Greeks is that given 
in Homer. Among the Greeks who had gone to 
Troy there were two physicians, Podalirius and 
Machaon. These were said to be the sons of 
^Esculapius, and that statement in itself is sufficient 
to cast great doubt on the existence even of these two 
men, but what is said about them helps us to under- 
stand the estimation in which physicians were held 
at this early date. Paris in the third battle wounds 
Machaon, and Nestor bears him rapidly away in 
his chariot from the battle-field towards the fleet. 
Idomeneus urges Nestor to carry Machaon away 
quickly, for he says — 

" A wise physician, skilled our wounds to heal, 
Is more than armies to the public weal." 

The siege of Troy took place somewhere about 
uoo B.C., and even if Homer's account is far from 
contemporary, it helps to establish the importance 
of medicine at a very early date. Arrows were the 
chief weapons of war then, and much skill is needed 
to remove an arrow safely from the body, as surgeons 
of the present time find who have to treat those 
wounded in fighting against savage races ; for the 
barbs prevent the withdrawal of the arrow. 

Much knowledge of the value of drugs was also 
possessed, as I have mentioned, by many women, and 
even in Homer we hear of Agamede, who was said 

24 



The Medicine of the Past 

to know the virtue of every plant that grew on the 
earth. 

In later times in Greece the practice of medicine 
was associated with the work of certain temples dedi- 
cated for the most part to ^Esculapius, the God 
of Medicine. Each of these temples was situated in 
the neighbourhood of some mineral spring, which 
was of importance in the treatment employed. 

To these temples repaired those who were suffer- 
ing, and the priests treated them to the best of their 
ability, partly by hygienic measures, by exercise, by 
baths, and by draughts from the spring, partly by 
drugs, and even by operation. The grateful patients 
made offerings to ^Esculapius for their recovery, 
and sometimes tablets were put up, setting forth the 
symptoms from which they had suffered and the 
means adopted for their relief. Some of these tablets 
still remain. These temples corresponded to modern 
spas and hospitals ; for the most part they were situ- 
ated in the healthy air of the country, generally near 
a medicinal spring, as mentioned above, and we may 
be sure that the pure air, the medicinal waters, and 
the simple diet contributed to the recovery of the 
patients. The most famous of all these temples was 
that situated in the Island of Cos in the ^gean Sea, 
where Hippocrates was born. 

Rome owed its medicine to Greece. Most of the 
physicians practising medicine in Rome in the later 
republican times and in the earlier portion of the 
Empire appear to have been Greeks. Many of them 
were slaves, and some of them had been specially 
educated as doctors at the cost of their owners, so that 
they might be available at all times. Judging by the 
treatises which have been left to us, the physicians 

25 



The Medicine of the Past 

of Rome attained to no small degree of skill both 
in medicine and in surgery. For the most part their 
knowledge of anatomy was very limited, and as it 
was not considered right to dissect the human body, 
they depended chiefly on the examination of the 
bodies of monkeys for their anatomy, for the resem- 
blance to the human body was considered sufficiently 
close to justify conclusions based on them. In the 
Roman Empire for many centuries of the present 
era the practice of medicine degenerated for the most 
part into a slavish adherence to the teaching of the 
ancients, and the writings which we now possess 
consist mainly of commentaries on and amplifica- 
tions of the texts of classical writers on medicine. 

In the British Isles before the Norman Conquest 
it cannot be said that the practice of medicine had 
reached a high degree of development. 

A little knowledge of the classical writers had 
filtered through, but for the most part medicine was 
based on tradition, and the virtues of herbs are re- 
corded in several Anglo-Saxon manuscripts, in which, 
mixed with discourses as to the virtues of plants, are 
directions for the use of certain incantations. In 
Anglo-Saxon Herbals we find a curious blending of 
superstition and a knowledge of the properties of 
plants. It was supposed that bleeding could be 
stopped by saying certain words, and diseases were 
thought to be curable by the wearing of a precious 
stone or the foot of a hare. It was thought that the 
rarer a substance was, the more valuable it must be, 
and valuable not merely as estimated by the money 
it cost to obtain it, but by its effect in the treatment 
of disease. We find also that many substances 
which few nowadays would like to take as medicine 

26 



The Medicine of the Past 

were then common ingredients of many prescriptions. 
Snails and ants and snakes were all considered of 
worth, as were also many other even less pleasant 
things. 

Elaborate directions were sometimes given as to 
the conditions under which a plant was to be selected 
for the preparation of the medicine. In some cases 
a moonlight night must be chosen ; in others an 
eclipse conferred value on a herb. The day of the 
week was also not without importance, and saints' 
days were of especial efficacy. 

On the whole, medicine advanced more rapidly 
than surgery ; gradually the knowledge of the pro- 
perties of plants became more and more exact ; gradu- 
ally the recognition of the meaning of symptoms 
became more and more accurate ; and we often cannot 
fail to wonder at the accuracy with which these old 
physicians interpreted the meaning of symptoms and 
prescribed for their relief. On the whole their de- 
scriptions of diseases are very brief, but here and 
there we can recognise the occurrence of diseases 
which have only been described with accuracy within 
recent years. During those centuries, which are often 
called the Dark Ages, the scientific study of medicine 
almost ceased in Europe, and only at Salerno in 
Italy did true medicine survive. It still existed 
amongst the Arabs, and moreover progressed, and 
even at the present day we possess a large number 
of treatises in Arabic, bearing witness to the care 
and assiduity with which the medical sciences were 
studied by them. Some, indeed, of these Arabic 
treatises were merely translations of Greek and Latin 
authors, but many of them were original. Rhazes, who 
is mentioned by Chaucer, and who lived in the tenth 

27 



The Medicine of the Past 

century, was the first to give an account of u small- 
pox," though it is probable that the disease had 
existed ages before. 

With the revival of learning, medicine also made 
a fresh start, and the most important factor in for- 
warding its progress was the increased study of 
anatomy, which then only really began. With the 
discovery of the circulation of the blood by Harvey 
a new impetus was given to the study of physiology, 
and indirectly this led greatly to the advance of 
medicine, for it enabled diseases of the heart and 
blood-vessels to be more thoroughly understood. 
The introduction of the microscope assisted greatly 
in the general advancement, for by its help the 
minute structures of the body became more clearly 
known. 

I have sketched briefly the progress of European 
medicine from its early days in Greece to the present 
time, to show that medicine had a lowly origin, 
and that it reached its present height only after 
many centuries. Many a time during those long 
years progress has ceased, sometimes the science 
has retrograded, but after a time once again a step 
forward has been taken. We must not imagine that 
we are within sight of perfection in the practice of 
medicine ; our successors will surely perceive many 
faults in our methods, and mistakes in our practice, 
but we shall have done our part if we have striven 
to our utmost to advance even a little the science 
of medicine. 



28 



CHAPTER III 

THE CAUSES OF DISEASE 

It is very difficult, if not impossible, to lay down any 
precise definition of disease, and we may be content 
with saying that it is a deviation from health. Such 
a deviation may be caused by one or other of two 
conditions. Either it may be due to some bodily 
defect which has been inherited, or it may proceed 
from some cause coming from without. It is im- 
portant to bear in mind that in many cases diseases 
which are said to be inherited have not existed in the 
child at birth, but they have affected the child be- 
cause he has inherited a constitution which rendered 
him liable to be attacked by that disease ; that is to 
say, he has inherited the predisposition to the disease 
but not the disease itself. Thus pulmonary phthisis, 
or u consumption " itself, is not inherited, but merely 
the predisposition to it. 

Another classification of the causes of disease is 
based on their mode of action ; they are divided into 
direct (or exciting) and indirect (or predisposing) 
causes. But this is not so simple a classification as 
might at first sight appear ; for the very same con- 
dition may act according to circumstances in one 
case as a direct cause, in another indirectly. Simple 
examples of this may be found in cold and hunger. 
When cold is applied to a part of the body it may 
cause, as a direct effect of its application, definite 

29 



The Causes of Disease 

harm, such as frost-bite, or death from exposure may 
result as a direct effect if the whole body is subjected 
to severe cold, for the vital processes cannot go on 
unless a certain temperature is maintained. The 
effect of cold may, however, be indirect ; it may 
weaken the tissues so as to make them more easily 
attacked by disease-germs such as those causing 
pneumonia. In the latter case the cooling of the 
body has made the tissues less able to withstand the 
assaults of bacteria, and so the cold has contributed 
to the disease; it has acted as a "predisposing" 
cause, but its action was not essential for the pro- 
duction of the pneumonia, for that disease may arise 
without the occurrence of any previous chilling. The 
bacteria of pneumonia are the essential element in 
the disease, and by them the disease has been started ; 
the bacteria therefore form the "exciting" cause. 
Similarly, if sufficient food be not taken, the powers 
of resistance of the body will be materially lessened, 
and some diseases will more readily attack it, while if 
no food at all be taken, death may be the direct result 
of the want of food, as in death by starvation. 

Until the " exciting causes " of disease were known 
the predisposing causes were looked upon as all- 
important ; but when, with the advance of bacteri- 
ology, we became acquainted with the important part 
played by bacteria, it grew gradually to be the 
custom to ascribe the origin of the disease entirely to 
bacteria. 

We have, however, learned, and in fact we are still 
learning, that bacteria in many cases are unable of 
themselves to give rise to disease in a person other- 
wise in perfect health, and that unless some additional 
factor is present, the disease will not appear. The 

30 



The Causes of Disease 

additional factor varies in nature in different cases, 
but it may be described in general terms as some 
impairment of the resisting powers of the body as a 
whole or of a special organ. This impairment may 
be temporary only, and dependent on some special 
cause, or it may endure throughout life. We know 
that bacteria may sometimes invade the body and yet 
not give rise to disease ; the germs of pneumonia are 
often found in the throats of healthy people, and 
these germs do not, apparently, do any harm, until 
some change in the power of resistance of the lungs 
enables them to invade the lungs and give rise to 
pneumonia. Therefore we must be careful to esti- 
mate the germ at its true value, and not to think too 
much of its mere presence, while at the same time 
we must appreciate the very great importance of 
predisposing conditions. 

In discussing the various causes of disease, it will 
be well to consider all causes, whether predisposing 
or exciting, and these may be conveniently divided 
into four groups : — 

i. Mechanical causes. 

2. Physical causes. 

3. Chemical causes. 

4. Parasitic causes. 

1. Mechanical Causes 

In the mechanical causes we include such forms of 
injury as cutting and stabbing, the wounds caused 
by a bullet, and the injuries brought about by falls. 
Little needs to be said of these. They do harm 
partly by shock and partly by tearing blood-vessels, 
or by injuring the nervous system. A few forms of 

3i 



The Causes of Disease 

mechanical injury, however, deserve a fuller descrip- 
tion. Concussion of any tissue may occur, the struc- 
ture being shaken violently, but it is in reference 
especially to a form of injury to the brain that the 
term is used. A blow or fall on the head may pro- 
duce one or more kinds of injury, but we are now 
considering only concussion. The brain is composed 
of a semi-soft material, and when it receives a sudden 
and violent shock many minute blood-vessels (or 
capillaries) are torn and small haemorrhages occur 
into the substance of the brain, and these disturb- 
ances give rise to unconsciousness, which may be 
very slight and of but little importance, or it may 
lead to the most serious results. 

Great changes in atmospheric pressure produce 
effects, partly as a result of the variation in the 
mechanical effect on the body and partly also in 
other ways. At great altitudes the diminution of 
pressure of the air on the surface of the body leads 
to some disturbance of the circulation, but the main 
harmful effects are due to a diminution of the amount 
of air taken in at each breath, and consequently to 
a deficiency in the amount of oxygen supplied to the 
tissues ; it is probable that in some other ways also 
great heights do harm, but the matter is not com- 
pletely settled yet. 

Of more practical importance, at the present time, 
is the harmful effect of an increased pressure of air. 
This is seen to a small extent in those who work in 
diving bells, but it is most marked in those employed 
in " caissons." A " caisson," it may perhaps be ad- 
visable to explain, is a case or framework without a 
floor but closed in above ; it is sunk into a river and 
it contains men who excavate the bed of the river. 



The Causes of Disease 

In order to keep out water, air is pumped into the 
caisson, so as to produce a pressure which is greater 
than that exerted by the water. Roughly, it may 
be said, that for every two feet below the surface 
of the water the atmospheric pressure has to be in- 
creased by one pound on the square inch. Thus, 
at a depth of sixty feet, the natural atmospheric 
pressure would have to be increased by thirty pounds 
on the square inch. Each caisson has an " air lock/' 
through which the workmen have to pass before 
they enter or leave the caisson. This "air lock" 
is a small air-tight room with two air-tight doors, one 
opening into the caisson and the other leading to the 
outer air. In each u air lock," as men prepare to enter 
the caisson the pressure is slowly increased to the 
pressure in the caisson, and as the men leave, the 
pressure in the "airlock" is slowly reduced to that 
of the atmosphere. The symptoms of " caisson dis- 
ease " do not as a rule manifest themselves until after 
the workman has left off work for the day. The 
most common symptom is some form of paralysis. 
This appears to be produced by too sudden a reduc- 
tion of pressure, which seems to cause gases to 
be given off in the liquids and tissues of the body, 
doing much damage. Fat especially appears to 
absorb a great deal of gas at the higher pressure. 
For the prevention of the disease it is advised that 
no workman who is stout should be employed in 
caissons, and more important still, the transition from 
the high pressure to the normal should be very slow. 

2. Physical Causes 

Heat and Cold. — One of the most important of the 
physical causes of disease is change of temperature. 

33 C 



The Causes of Disease 

The human body possesses a marvellous adaptability 
to heat and cold. It can endure the heat of the 
tropics and even higher temperatures ; for men can 
survive after being submitted to a temperature of 
260 Fahr., that is to say, nearly 50 above the 
boiling-point of water. This is possible because of 
the rapid evaporation of perspiration from the surface 
of the body ; this evaporation has a twofold effect, 
for on the one hand, when the water of the perspira- 
tion is converted into vapour, a large quantity of heat 
is abstracted from the body, and on the other hand 
the layer of air immediately in contact with the body 
is also cooled, and this protects the skin, as air is a 
bad conductor of heat. Those people can endure high 
temperatures most easily who perspire most readily. 
If, however, the surrounding air is saturated with 
moisture no evaporation can take place, and as a 
result, a high temperature is much more unpleasant 
and harder to bear. Climates that are hot and dry, 
such as that of Australia, are much more endurable 
than those which are hot and moist, such as the 
climate of the tropical West Coast of Africa in the 
rainy season. 

In the same way as man can endure very high 
temperatures, so also can he survive exposure to low 
temperature, even when the surrounding air is as 
cold as -70 Fahr., or ioo° below the freezing- 
point of water ; even at such a temperature as 
this life is possible. Here, also, the slight con- 
ducting power of the air makes it serve as a coating 
to the body, but if there is much wind, the heat is 
carried off more quickly and the temperature is less 
endurable. Both of these very high and very low 
temperatures can be borne only if the exposure to 

34 



The Causes of Disease 

them is not too protracted. When, however, heat or 
cold is applied to the body directly, as by a solid 
body, the temperature may be much less severe and 
yet prove very harmful. Burns and frost-bites both 
destroy the life of the tissues by killing the living cells. 
Burns and scalds differ only in that a burn is inflicted 
by a solid body and a scald by a hot liquid ; the dif- 
ference practically disappears when the heated liquid 
is one with a boiling-point much above that of water. 

Light. — Light may, of itself, do harm to the body, 
though this is more likely to occur in tropical 
climates than in a country with the latitude of 
England. The pigmentation of the skin seen in 
the coloured races appears to have developed to 
prevent the harmful effect of excessive sunlight on 
the body. Though there is a certain amount of 
evidence that an excess of light has an injurious 
effect, yet we know little of how it acts. The X-rays 
are capable of producing severe inflammation of the 
skin and even of the deeper structures ; and though 
we know little of the exact nature of the rays, we are 
now able to regulate their action so as to prevent 
any harmful effects. Radium has an action on the 
tissues in many respects resembling those produced 
by X-rays. 

Electricity, — Severe injuries and deaths from light- 
ning have been known as long as man has lived, and 
these cases exhibit the most startling harmful effects 
of electricity, but the wide extensions of the com- 
mercial and domestic uses of electricity have led to 
a number of deaths from it. The higher voltages are 
more dangerous, for death hardly ever occurs when 
the voltage is below ioo, yet the fatal result depends 
not so much on the voltage, but chiefly on the passage 

35 



The Causes of Disease 

of a large quantity of electricity through the body, 
for the voltage may be exceedingly high and yet 
serious results may not be produced if the quantity 
is very small. The skin offers a great resistance to 
electricity, especially when quite dry ; if the skin is 
wet its resistance is very little. This point is of 
importance in dealing with accidental leakages of 
electric current ; it is far safer to touch electric wires 
with dry hands than with hands which are moist. 

3. Chemical Causes 

Some chemical substances harm the body by their 
direct caustic action on the tissues ; this is seen in 
the effect of sulphuric acid or " vitriol," as it is often 
termed ; it burns the skin and so destroys it. Another 
example of a substance with the same kind of action 
is quicklime. 

Most chemical substances, whether poisonous or 
not, act indirectly after undergoing absorption into the 
blood, by which they are carried all over the body, 
and then they exert their action on certain tissues 
especially, for few, if any, chemical substances act on 
all the tissues of the body. Some act through the 
nervous system, some on the muscles, some on the 
heart or blood-vessels, and some on the organs con- 
nected with digestion, such as the liver. 

At present we do not know why a chemical substance 
acts on one organ rather than another ; though we can 
understand that if a poisonous substance is excreted 
by the skin it may have a special action on the skin. 

A substance that may be present in food or drinking 
water in minute quantities, and when thus taken is 
harmless, may be definitely poisonous if administered 
in large doses ; so that with all these chemical causes 

36 



The Causes of Disease 

of disease the quantity taken is of the first importance 
in determining the effect. Some of the chemical 
substances which harm the body are not taken in 
from outside, but are manufactured by the body itself. 
For instance, in some forms of indigestion or mal- 
digestion of food, substances are formed which have 
a directly harmful effect on the body, and may give 
rise to diseases. Thus the poisonous substances that 
cause the symptoms of gout are not taken into the 
body in that form, but are made in the body itself by 
the action of abnormal vital and chemical processes. 

4. Parasitic Causes 

These fall naturally into two groups. First there 
are the larger parasites which are visible to the naked 
eye, some of which are vegetable in nature and some 
are animal. As examples of the larger animal para- 
sites we may mention the tapeworm, the fluke, which 
is the cause of much illness among sheep, and the 
" trichina," which is the cause of " trichinosis/' Some 
of these larger parasites do harm by absorbing nutri- 
ment from the body, some by destruction of the 
tissues, and some by producing chemical substances 
which act as poisons to the body. 

The great importance of some of these larger para- 
sites can be appreciated from an account of ankylo- 
stomiasis. The inhabitants of Egypt, Brazil, Burmah, 
and some parts of India are liable to a peculiar form 
of anaemia, which does not respond to ordinary 
methods of treatment and is at times fatal. The 
disease was known for many years before its cause 
was discovered, and it is now certain that this endemic 
anaemia is due to the presence, in the upper part of 
the intestine close to the stomach, of a small worm 
less than half an inch long. It is attached to the 

37 



The Causes of Disease 

lining membrane of the bowel, and it lives by sucking 
the blood of its host. It is called ankylostoma, and 
the disease is known as ankylostomiasis. The worm 
had been described long before its association with 
the endemic anaemia was recognised. Until recently 
there was no record of the disease occurring in 
cooler climates, but it is not rare in Italy, and when 
Italian labourers took part in making the St. Gothard 
Tunnel, the disease broke out there and was very pre- 
valent. In mines it has appeared, even in the British 
Isles, and though the embryos are killed by frost, the 
temperature of many mines is sufficiently high, even 
in winter, to allow the disease to be persistent. 

It is not certain how the animal obtains admis- 
sion to the body, but it is probably through contami- 
nated food, or perhaps through contaminated drinking 
water, though there is some evidence that it may 
enter through the unbroken skin. 

Brickmakers are also liable to be infected, and in 
Egypt it occurs among the peasants working in damp 
earth. It is curious that many of the sufferers from 
this disease take pleasure in eating earth, and in this 
way the infection of the body is kept up even if this 
practice does not start the disease. The ankylostoma 
may exist in persons in apparently good health ; and 
it has been calculated that nearly three-quarters of the 
people in some districts in India possess this parasite. 
Suitable treatment, now that the cause is known, has 
been very successful in curing the condition. 

The microscopic parasites are described in the 
chapter on Germs, and every year we are learning 
of fresh instances in which harm is done to the human 
body by some of these minute plants and animals. 
Fortunately the vast majority of the microbes known 
to us have no harmful effect on man, but the number 

38 



The Causes of Disease 

that can and do attack him is still very large, and 
were it not for certain powers of defence described 
in the chapter on Immunity, man would soon be 
exterminated. 




from " Anaesthetics, Antient and Modern," by permission of Burroughs Wellcome & Cp. 

AN OPERATION ON THE LIVER 
From a MS. of the Fourteenth Century 



CHAPTER IV 

GERMS 

Every one nowadays knows that many of the most 
important diseases that affect the human race are due 
to minute living bodies, generally called germs, and 
the object of this chapter is to give an account of the 
nature and the mode of action of these little bodies. 

Germs have many names ; they are sometimes 
called microbes and sometimes micro-organisms, 
and to some special forms of them are given other 
names still, such as bacteria and bacilli. These germs 
are minute plants or animals, very low in the scale 
of life, in fact so low are they that it is sometimes 
difficult or even impossible to say with certainty 
whether some of them really belong to the animal 
or the vegetable kingdom. In some respects they 
resemble one, and in some points they resemble the 
other, but, for the most part, they belong to the 
vegetable kingdom, and therefore we look upon most 
of them as minute plants. In no way, however, do 
they resemble the plants with which we are commonly 
acquainted ; for they have no roots, and no stem, 
and they do not flower. 

The first idea that must be grasped with regard to 
these germs, is that they are exceedingly minute. 
With our ordinary ideas of size it is very difficult 
to appreciate any bodies so exceedingly small as most 
germs are. In the first place they are not visible to 

40 



Germs 

the naked eye, and that fact itself shows they must 
be less than one five-hundredth (xihr) P ar * °* an * nc h 
in length, for that is about the limit of our unaided 
vision. One of the largest germs that may infect the 
human body is the anthrax bacillus, which causes 
the disease known as anthrax : it is liable to occur 
in this country amongst those who handle foreign 
hides, which are often infected with it. Even the 
anthrax bacillus measures only one eight-thousandth 
OsifW) P ar "t °f an mcn m length ; that is to say, if 
8000 of these germs were placed end to end they 
would measure only one inch from one end to the 
other of the whole line. Now it is very difficult to 
appreciate so small a body as this, but, as I have 
said above, the anthrax bacillus is one of the largest 
of those causing disease, and the majority of germs 
are much smaller even than this. One of the smallest 
of those known is the germ that causes influenza, 
and this is only about one tenth the size of the 
bacillus of anthrax ; that is to say, 80,000 of these 
germs placed end to end would only measure one 
inch. This germ of influenza represents nearly the 
limit of our vision at present by means of a micro- 
scope, and there are reasons for thinking that germs 
exist which are even more minute — in fact, so small 
that we cannot see them even with the highest powers 
of the microscope, and therefore as yet we cannot 
obtain any visual proof of their existence. It is, 
to say the least, very unlikely that the limit of minute- 
ness of germs should practically coincide with our 
limit of vision by means of the microscope. 

Up to now I have only spoken of the number of 
germs which could be put into an inch in length ; 
the number increases enormously when we consider 

4i 



Germs 

an area of surface, while if we estimate the number 
which would be required to fill a certain volume, 
it is utterly inconceivable. For instance, a cubic 
inch could contain more than five hundred millions 
of millions of the influenza bacillus, or to express 
the same idea in another way, a single drop of liquid 
could contain several million germs. 

Germs are no new creation ; it is probable that 
they existed at a very early time in the history of the 
world ; we have evidence that they were in existence 
at least as long ago as the carboniferous period, when 
the great coal measures were being formed, for, in 
the beds of coal, germs of various kinds have been 
found, and we are fully justified in thinking that they 
had existed for long ages before this. Even if we 
only date them from the time when coal was being 
formed they must have existed for millions of years. 

Germs are very widely distributed. They are 
found everywhere on the surface of the earth except 
high up on lofty mountains. Everywhere in the air 
they are to be found except at great heights. All 
waters contain them, both fresh and salt ; even in 
the sea far from land they may be found, though it 
is certain that they are far more plentiful nearer 
shore. All rivers, ponds, and lakes contain them, 
though in some waters they are far more numerous 
than in others. There are, however, some exceptions 
to this rule of their prevalence in all waters, for 
springs which rise from great depths, and the water 
from artesian wells, are practically always germ free. 
In the soil they are to be found even at a depth 
of many feet from the surface, but deep down in 
untouched ground and undisturbed rocks no living 
germs can be discovered. Although they are so 

42 



Germs 

widely distributed they' are not prevalent everywhere 
to the same degree. In some places they are scanty, 
in others exceedingly numerous, and it is especially 
in places inhabited by men or animals that they are 
most plentiful. For instance, in the air of the country 
there may be only one or two germs in each cubic 
inch, but if we take a cubic inch of the air of a 
town, especially in those parts which are most crowded, 
we may discover several hundreds of germs in every 
cubic inch of the air. 

What are germs like ? Germs vary enormously in 
shape and in size, but for the most part they are 
little rod-shaped bodies — that is to say, they have the 
form of little sticks. Some are rounded or oval like 
grapes or berries ; some again are coiled into a 
spiral like a corkscrew ; sometimes they form long 
strings, the germs being united together by their 
ends ; and sometimes they form masses not unlike 
bunches of grapes. Germs differ from one another 
also in the power of movement. Some are absolutely 
immobile, that is, they cannot stir from the place 
where they are ; others again are provided with means 
whereby they can swim about in a liquid and so 
make their way from one part of it to another ; and 
this power of movement may easily be of importance 
in the production of disease. The minuteness of 
germs is remarkable, but even more remarkable is 
the rapidity with which they increase in number. The 
multiplication of germs is for the most part extremely 
simple. Each little rod grows in length until it 
measures about twice as long as at first, and then 
a transverse partition develops in the middle and 
two bacteria are thus formed. These may remain 
attached to one another more or less firmly, and so 

43 



Germs 

form the long threads already mentioned, or they may 
separate. Sometimes germs have another method of 
increasing in number, which is employed when the 
external conditions are unfavourable for the life of 
the organism. This other method is by the formation 
of spores. These may be compared to the seeds of 
ordinary plants, and they seem to be formed chiefly 
when there is not enough food for the germs. The 
spores can remain a long time without food, and 
yet they may begin to grow when the conditions 
are once more favourable for them. 

The rapidity with which germs increase may be 
very great. It is clear that if one germ can become 
two in a quarter of an hour, at the end of an hour 
it would have formed sixteen, at the end of three 
hours it would have formed more than 4000 germs ; 
in ten hours the number formed would require, if 
this rate of production continued, more than twelve 
figures to represent it ; while, if we estimate the 
number that could, theoretically, be formed in twenty- 
four hours we should reach a sum requiring dozens 
of figures ; a number such as this is utterly beyond 
our comprehension. Of course this rate of pro- 
duction is not always maintained ; some germs multi- 
ply quickly, and others take longer to increase in 
number. If food falls short, or if the temperature 
is too high or too low, then the increase in number 
is much reduced, and it may come to an end. I 
have, however, said enough to show that the mar- 
vellous power of multiplication possessed by germs 
must have important results if those germs are 
capable of harm. 

It is especially in the power germs possess of offer- 
ing resistance to unfavourable conditions that they 

44 



Germs 

manifest the greatest difference from higher plants. 
A comparatively small change in the conditions pre- 
vailing in a country will often prevent a plant from 
growing well. A little increase or decrease in the 
humidity of a climate, or the occurrence of a few 
severe frosts, may put an end to the growth of some 
species of plants in a particular district where they 
may have lived and flourished for many years. It is, 
however, not so with germs ; for the most part they 
possess a marvellous capability of withstanding ad- 
verse conditions, amply sufficient to destroy the 
vitality of higher plants. Even when the germs 
themselves are destroyed their spores may survive, 
and, awaiting favourable conditions, they may at 
length germinate and give rise to active forms. 

Ordinary cold has no effect whatever on the vital- 
ity of germs. It is true that they become less active 
under the influence of cold ; if they possess the 
power of movement their motility is reduced, and 
when the cold reaches the freezing-point of water, 
they cease to move at all. The power of multipli- 
cation also is in abeyance during exposure to low 
temperatures, but should the temperature rise again 
to one favourable to them the germs resume at once 
all their former powers exactly as if they had never 
been exposed to cold at all. 

So far I have spoken of cold of ordinary degrees, 
but the results are practically identical when germs 
are exposed to temperatures far lower than that of 
the freezing-point of water. The most intense cold 
than we can produce appears to have little effect ; 
for germs and their spores have been exposed for 
more than a week to the temperature of liquid air, 
that is, nearly 400 Fahr. below freezing-point, and 

45 



Germs 

yet, when at the end of the time they were removed 
to a favourable temperature, they grew freely. The 
temperature of liquid air is an intensity of cold which 
probably never occurs naturally on the earth, in fact 
it may be described as twice as much colder than ice 
as ice is colder than boiling water. But we are able 
to produce, artificially, temperatures even colder than 
this. The temperature of liquid hydrogen, which is 
nearly 500 below freezing-point, did not affect the 
vitality of some germs which were exposed to it for 
ten hours. I have said above that the activity of 
germs diminishes as the temperature approaches the 
freezing-point of water, but certain bacteria have 
been found capable of growing on ice. 

So much for the effect of cold. When we endeavour 
to try, by experiments, the effect of heat, we find that 
usually germs cease to grow when the temperature 
reaches 120 Fahr., and few can survive, if no spores 
are present, a temperature of 150 Fahr., and this is 
a higher temperature than the hand can bear. There 
are, however, some germs which flourish at a tem- 
perature higher than this, about 160 Fahr., and some 
of these are found living, growing, and multiplying in 
hot natural springs. These germs, which appear to 
enjoy these high temperatures, are called "thermo- 
philous" or " heat-loving," and they are of no small 
importance, for they exist in, and in fact are the cause 
of, many natural fermentations in which there is an 
evolution of heat often reaching a high degree. An 
example of this may be seen in the heating of manure 
heaps which are utilised for forcing plants ; it is also 
seen in the heating which is so likely to occur in hay- 
stacks, if the hay has not been thoroughly made : and 
if this is allowed to continue the temperature may rise 

46 



Germs 

so high as to set fire to the stack. A similar heating 
is liable to occur amongst large masses of tobacco. 
These thermophilous bacteria flourish best at a high 
temperature, and in fact for every germ that exists 
there is a temperature which suits it best and at 
which it can grow most freely. This is called its 
u optimum " temperature. Most germs, however, are 
destroyed in a very few minutes in boiling water, but 
their spores, if present, are much more resistant, and 
prolonged boiling is necessary if an absolute freedom 
from living germs is required. The easiest mode of 
effecting this is to boil, on two or three occasions, 
at intervals of twenty-four hours; for after the first 
boiling most of the spores which have survived will 
have developed into bacteria before the second boil- 
ing, and so will be easily destroyed, and the third 
boiling will assuredly put an end to any which have 
escaped previously. This method of destroying germs 
by boiling is widely used in the modern practice of 
surgery, for it is essential that no germs should 
be present if the best results in surgery are to be 
obtained. 

When dry heat is used to destroy germs it must 
be much more intense if the destruction of the germs 
and their spores is to be complete. It is suggested 
that the greater resisting power of spores is due to 
the fact that they contain less moisture than the 
germs themselves. A temperature of 400 Fahr. of 
dry heat will certainly render free from germs every- 
thing submitted to it. This baking of infected 
material is therefore looked upon as the safest method 
of destroying the contagion in infectious diseases such 
as scarlet fever or smallpox, and it is the method 
almost universally employed by municipal bodies to 

47 



Germs 

carry out disinfection of clothes and bedding after 
cases of infectious illness. 

Germs are but little affected by pressure ; for no 
effect was apparently produced when some germs 
were submitted to pressures up to one ton on the 
square inch ; when the pressure was removed they 
appeared to be none the worse for it. When, how- 
ever, the pressure was increased greatly, so as to 
amount to some twenty tons on the square inch, many 
germs were destroyed, though even here some sur- 
vived this terrible ordeal, and these survivors were 
chiefly spores. 

Light, especially the light of the sun, has a truly 
wonderful effect on nearly all forms of germs. Almost 
without exception they are killed by a not very pro- 
longed exposure to the rays of the sun, and the 
electric arc has a similar though, of course, less 
intense action. At first it was thought that the heat 
of the solar rays might be responsible for the death 
of the bacteria, but it has been shown by careful ex- 
periment that the rays of light themselves have a 
power of destroying germs quite apart from any 
heating effect which may be produced. This has 
been proved by interposing a bottle containing a 
liquid which does not allow the heat rays to pass 
through, though the light rays are unaffected. It 
has even been discovered which of the rays of light 
are most effective in destroying germs. All who 
have had anything to do with photography are aware 
that light rays of different colours have different 
powers of affecting the photographic plate. The 
violet rays at one end of the spectrum are much more 
effective in photography than are those which are 
nearer the red end of the spectrum ; but even more 

4 8 



Germs 

effective still in producing a photograph are those 
invisible rays which are beyond the violet rays and 
which are therefore spoken of as the ultra-violet 
rays. It is now known that the very same rays 
which are most effective in photography, namely, the 
violet and ultra-violet rays, are also those which have 
most power in destroying bacteria, while the rays 
near the red end of the spectrum have hardly any 
action on germs. This powerful action of the light 
of the sun in destroying germs is of enormous 
practical importance in Nature. Everywhere, when 
the sun is shining, in the air, in lakes, in rivers, and 
in the sea and on the land, all day long the light of 
the sun is destroying germs, and the action is fairly 
rapid. The knowledge of this fact helps us to under- 
stand one reason, at least, why rooms well lighted by 
windows are more likely to be free from disease than 
are those which are dark and gloomy. 

Even when the light is not sufficiently bright to 
kill the germs, or its duration of exposure is not 
sufficiently long, much good may be done owing to 
the effect which the light has in weakening the powers 
of the microbes and thus in lessening their oppor- 
tunities for harm. The fact that the electric arc 
lamp can be used for photography suggested that 
it should be employed for the destruction of germs, 
and there is no doubt that when the conditions are 
favourable, and the germs are not shielded by any 
intervening substances, the electric arc possesses a 
very definite power of destroying germs. These facts 
gave rise to the hope, a few years ago, that this power 
possessed by the electric arc lamp might be utilised 
for destroying harmful microbes in the human body, 
but up to the present it is generally agreed that it has 

49 D 



Germs 

not been found possible to utilise the electric arc 
lamp in the direct treatment of microbic diseases. 

Electricity has surprisingly little effect by itself. 
It is true that if an electric current be passed through 
a liquid in which living bacteria exist, numbers of 
them will die ; but this fatal effect is not directly the 
result of the electric current, as it is brought about 
by the action of chemical substances to which the 
electric current has given rise. I do not suggest that 
electric currents are useless in the treatment of 
disease, for frequently they are of very great value, 
but that value, so far as we know, does not depend in 
any case on the direct effect of the electricity on any 
germs which may be present. 

Many chemical substances have a very powerful 
effect on germs. Some of these chemical substances 
merely prevent the germs growing, without destroying 
them, but others have a direct action, killing the germs 
more or less quickly, and in this case, as in some 
others I have mentioned, it is found that the spores 
of the germs are much more resistant than the germs 
themselves. The value of chemical substances in 
destroying germs is now known to every one, and 
there are few who do not utilise the fact in some way 
or another. The use of antiseptic tooth powders and 
lotions for the purpose of keeping the mouth as free 
from germs as possible is very common. The value 
of vinegar for preserving some forms of food depends 
on its antiseptic action. Carbolic acid is widely used 
as a disinfectant. 

Many microbes die when buried in the earth, but 
some have been found to survive many years ; pro- 
bably they survive longer when they are in the spore 

5o 



Germs 

form. Nevertheless, though some germs are able to 
survive burial in the ground for years, many germs 
are rapidly destroyed by the action of the soil. 
Pasteur showed that the spores of the bacillus which 
causes anthrax were alive after they had been in a 
glass tube hermetically sealed for more than twenty 
years, but in this case they were subjected to no 
harmful influence. 

Drying, if not carried very far,.has but little perma- 
nent effect on many bacteria, though to others it 
proves rapidly fatal ; and absolute desiccation seems 
to destroy all forms of germs. 

If germs cause disease, how is it possible that any 
of us can survive when germs are as numerous and 
as widely spread as I have described above ? Fortu- 
nately for us, all germs are not harmful. Of the many 
thousands of germs which are known to us, only a 
very small proportion can give rise to disease in the 
human body, while on the other hand, many germs 
are of the greatest importance in daily life. If it 
were not for germs, malt would never give rise to 
beer, and the juice of the grape would never become 
wine. If it were not for germs no cheese would ever 
ripen, and dough would never rise. 

The special and much appreciated flavours of 
certain butters are said to be due to the presence of 
special germs. Vinegar is produced by the action 
of a particular kind of germ, and it would be easy to 
quote many more instances of the importance of the 
action of germs in daily life. When dead vegetable 
material is placed in the soil it cannot be utilised to 
make that soil more capable of producing plants 
until its structure has been changed by the action o' 

5i 



Germs 

certain germs which have this function. Every one 
interested in gardening knows the great value of a 
large supply of nitrogen compounds in the soil for 
the growth of crops ; it is therefore of great interest 
to know that within recent years we have learned that 
there are certain microbes specially associated with, 
and growing in, the roots of peas and beans which 
possess the power of taking nitrogen from the air and 
combining it, so that if may be utilised for the growth 
of plants. 

All germs give rise to certain chemical substances, 
and some of these are retained within the body of 
the microbe, and some are set free, and it is probably 
through the action of these chemical substances that 
germs produce many of the changes to which they 
give rise. I have so far spoken almost exclusively of 
germs which are vegetable in nature. There are a 
few which are really very low forms of animals, but 
these few animal germs produce some of the most 
important diseases in certain parts of the world. The 
best instance of a disease depending on an animal 
germ which I can quote is malaria. In this disease 
the minute animal, belonging to almost the lowest 
class of animals, obtains entrance into the body 
of the victim through the bite of a mosquito, and 
making its way through the blood it quickly enters 
a red corpuscle, in which it lives and multiplies, 
and which it ultimately destroys. Sleeping sickness, 
which has in the last few years attracted so much 
attention in Africa, is another instance of a disease 
caused by a germ which is animal in nature ; and the 
tsetse fly disease, so fatal to many of the lower animals 
in certain districts of Africa, is another instance of the 
same kind. Fortunately the tsetse fly disease never 

5 2 



Germs 

attacks human beings. At the present day we know 
much more about the importance of germs in the 
production of disease than was known even a few 
years ago, but it is not improbable that great additions 
will be made to our knowledge of this matter before 
many years pass by. 



53 



CHAPTER V 

THE MICROSCOPE IN MEDICINE 

The unaided eye of the physician is incapable of 
recognising the minute structures of the organs of 
the body in health and the changes which those 
organs undergo in [disease. Yet the knowledge sup- 
plied by the examination of healthy and diseased 
tissues has done as much as anything else to bring 
the medicine of the present day to the position to 
which it has now attained, and it is necessary for a 
due appreciation of modern medical methods that 
the use of the microscope as applied to medicine 
should be described. 

The simple lens was a necessary prelude to the 
compound microscope. That simple lenses existed 
long ago there can be no doubt, though we have 
no direct knowledge of their existence. A convex 
lens of rock crystal was indeed discovered by Layard 
when digging among the ruins of the Palace of 
Nimrud, but the lens, if it be a lens, was very crudely 
made. Its surfaces were far from spherical, and it 
could have given but little assistance in the mag- 
nification of objects. We have, however, indirect 
evidence. The ancients were very expert in the art 
of gem-cutting, and much of this work is so minute 
that it is almost impossible to believe that it was 
carried out without the assistance of a magnifying 
glass. We may take it therefore as practically certain 

54 



The Microscope in Medicine 

that at the time when the art of gem-cutting attained 
perfection lenses were known. In Europe convex 
lenses appear to have been employed for more than 
600 years in the form of spectacles, and though 
spectacles of native manufacture are widely used in 
China, there is, I believe, no evidence that they were 
invented before they appeared in Europe. The 
practice of making lenses for spectacles soon led to 
such good results that when the telescope was in- 
vented it was an easy matter to obtain the lenses 
suited for it. The invention of the compound micro- 
scope was more difficult, for the object glass required 
a lens of high curvature, such as were never re- 
quired for spectacles. At first glass globules made 
by melting threads of spun glass were employed, but 
their surfaces were not perfectly regular, and the 
results were poor. 

The celebrated Dutch observer, Leeuwenhoek, was 
the first to succeed in making simple lenses of very 
high curvature and with short focus, and though these 
were inferior in power of magnification to the com- 
pound microscope of that day, the picture was much 
clearer. For practical utility clearness of the image 
is of very much greater importance than merely great 
magnification. Leeuwenhoek was born in 1632 at 
Delft, where he worked as a lens grinder. He was 
very successful in grinding lenses of very short focus, 
and with these he was able to make several discoveries 
of no little merit in minute anatomy. His chief dis- 
covery was certainly that of the minute blood-vessels 
called capillaries and of the circulation of the blood 
through them. Harvey had perceived from the facts 
which induced him to believe in the circulation of the 
blood that there must be some minute communica- 

55 



The Microscope in Medicine 

tions invisible to the naked eye between the smallest 
arteries and the smallest veins. Leeuwenhoek's dis- 
covery, which was published in 1690, supplied just 
that step which was wanting for completing the proof 
of Harvey's doctrine of the circulation of the blood. 

After several failures to see the capillary circula- 
tion in the comb of a fowl and the membrane of a 
bat's wing, he succeeded ultimately with the tail of 
a young tadpole. He says : " I could distinctly per- 
ceive the whole circuit of the blood in its passage 
to the extremities of the vessels, and in its return 
toward the heart." Malpighi had indeed discovered 
the red corpuscles a little before this, but Leeuwenhoek 
saw them more clearly, and recognised that in man 
they were round, flattened discs, while in the frog 
they were oval. It was by the movements of the 
red corpuscles that he was able to perceive the blood 
circulating. By the aid of his lenses he made many 
discoveries ; he recognised the structure of the skin, 
of the teeth, and of other parts of the human body, 
and his researches in the minute anatomy of the 
lower animals and of plants were of great importance. 
His accounts of what he could see were not always 
accepted by his contemporaries, for apparently he 
could see more minute structures than others could 
see, even when using the same lenses. To Leeuwen- 
hoek must certainly be given the credit of being the 
first great worker with the microscope, even though 
he employed, not the compound microscope, but 
the simple lens. 

In the compound microscope in its simplest form 
two convex lenses are placed in such positions that 
the one near the eye can magnify the image formed 
by the other. The lens towards the object is called 

56 



The Microscope in Medicine 

the object glass, and the lens towards the observer's 
eye is called the eyepiece. The inventor of it appears 
to have been Zansz, a spectacle maker of Middleburg 
in Holland, about the year 1590. For a long time 
its faults were many and the images it formed were 
not at all clear. The two chief faults were spherical 
aberration and chromatic aberration. Owing to 
spherical aberration the image formed is not distinct ; 
and owing to chromatic aberration the image is irre- 
gularly tinted with various colours. These objections 
were removed partly by the work of Dollond and 
partly by Tulley, and it is worthy of note that Mr. 
J. J. Lister, the father of Lord Lister, assisted in 
perfecting the compound microscope, especially with 
regard to the improvement of the achromatic object 
glass. These improvements consisted mainly in 
making lenses of several pieces of different kinds of 
glass, so that the errors belonging to one piece cor- 
rected the errors of another. 

This was in 1830, and since that time progress has 
continued, until now microscopes are manufactured 
both by British and foreign makers which give 
wonderful results. The demands made on the micro- 
scope are increasing, and we appear almost to have 
reached the limit of progress of which the microscope 
is capable along its present lines. Doubtless in the 
future some new method will be devised to increase 
the capabilities of the microscope. 

We have traced thus far the microscope from its 
simple beginnings to the present very complex and 
accurate instrument, and now I will describe some 
of the ways in which the microscope is used for the 
study of disease. 

As the blood was the first object that engaged the 

57 



The Microscope in Medicine 

microscope in the study of the structure of the body, 
I will begin with an account of the way in which 
the microscope can assist in our study of the changes 
in the blood occurring in disease. The simplest use 
to which the microscope can be put in connection 
with the blood is to count the corpuscles. In health 
there are about five million red corpuscles in a cubic 
millimetre of the blood of a man, and about half a 
million less in the same quantity of the blood of a 
woman. In ordinary anaemia the red corpuscles are 
reduced in number, and we can form a more exact 
estimate both of the degree of anaemia present and 
of the effect of the treatment employed, if we know 
the number of red corpuscles present. In some cases 
of simple anaemia the number of red corpuscles 
may be greatly reduced, so that there are found to 
be in a cubic millimetre only about two million or 
even a smaller number than this. Sometimes in 
anaemia there is very little diminution in the number 
of red corpuscles, but each red corpuscle contains 
a smaller amount of haemoglobin — the red colouring 
matter of the blood, than it should. The result, so 
far as the symptoms are concerned, is the same. 
There will be less power of absorbing oxygen from 
the lungs and carrying it to the different parts of the 
body, and therefore shortness of breath will result. 

It is clear that simple anaemia may result from 
many causes. It exists for a time after any severe 
injury or operation in which a large amount of blood 
has been lost ; it may follow insufficient or unsuitable 
food, or it may be merely one manifestation of a 
disease. Iron is an essential constituent of the haemo- 
globin, and in many cases in which there is deficiency 
of haemoglobin, iron is often prescribed and proves 

58 



The Microscope in Medicine 

useful. It is probable, however, that in many cases 
there is no lack of iron in the food, but for some 
reason the body cannot assimilate it ; for the total 
quantity of iron in the body is not great, and it has 
been estimated at only a few grains. There is another 
form of anaemia called pernicious anaemia, which is 
a more serious malady ; but it is probable that under 
this name are included several distinct diseases. In 
the chapter on the causes of disease I have mentioned 
that a worm — the ankylostoma — may produce a very 
severe form of anaemia, and this at one time was 
looked upon as a form of pernicious anaemia. In 
this disease not only is the number of corpuscles 
diminished — and it may fall to half a million or even 
to two hundred thousand in the cubic millimetre — but 
many of the red corpuscles have unusual shapes. It 
will be seen, therefore, that the examination of the 
blood and the enumeration of the red corpuscles may 
be of great importance. I will now give a short 
account of the method employed for counting the 
corpuscles of the blood. 

It would be hopeless to attempt to count the 
corpuscles of the blood as it is drawn from the body, 
for it contains so many corpuscles that they cannot 
all be visible at once, even if a very thin layer be 
taken. Therefore, the blood has to be diluted. The 
lobe of the ear or the ball of a finger is pricked 
with a clean sharp needle, and a small quantity of the 
blood is drawn up into a narrow tube of known 
volume. When sufficient has passed into the tube 
reaching to a certain mark, this amount of blood is 
thoroughly mixed with two hundred times its volume 
of a liquid which prevents clotting, and then a minute 
drop of this is placed on to a microscopic glass slide, 

59 



The Microscope in Medicine 

on which is a " counting cell." This cell consists of 
a glass ring, one tenth of a millimetre high, cemented 
to the glass slide. The space enclosed is divided- by 
fine lines into squares, such that the volume marked 
out by each square is equal to ^^nnj- of a cubic milli- 
metre. The drop is covered with a piece of extremely 
thin glass. When the corpuscles have had time to 
settle, the slide is examined under the microscope, 
and then the observer is able to count the number of 
red corpuscles in each small square. If this number 
is multiplied by 4000 and then by 200 (the degree of 
dilution), we obtain a result showing the number of 
red corpuscles in a cubic millimetre. Greater accu- 
racy would be obtained if the observer counts the 
number in ten squares and divides the total by ten, 
before multiplying by 4000 and by 200. 

To take an example : ten squares are counted and 
it is found that in the ten squares there are 45 red 
corpuscles ; this, divided by 10, will give an average 
of 4! in each square. If 4J be multiplied by 4000 
and then by 200, we obtain 3,600,000 as the number 
of red corpuscles in a cubic millimetre. 

It is clear that the larger the number of cells 
counted the more accurate will be the result. 

Similarly the white corpuscles may be counted, and 
at one time that was considered sufficient. But now 
it is known that there are several kinds of white 
corpuscles, and for diagnostic purposes it is necessary 
to know how many of each kind are present. These 
different forms of white corpuscles can be best dis- 
tinguished if they have been stained, and for this 
purpose a u film " preparation has to be made. 

A very thin layer of blood is spread out on a cover 
glass and dried. The film can then be stained, and 

60 




Crystals from Human Blood 



It is often possible to identify the source of blood by means of crystals which 
can be obtained from it, for each race of animal has its own special form of blood 
crystal. The large crystal at the margin exhibits the typical shape. 

B. Crystals from the Blood of this Baboon 

These show some resemblance to crystals from human blood. 



The Microscope in Medicine 

when the cover glass has been suitably mounted, the 
white corpuscles can be examined and their relative 
proportions ascertained. It may be asked what is the 
use of knowing the proportions of the different kinds 
of white cells. The matter is much too complex to 
describe, but as an example of the kind of informa- 
tion which may be obtained from a "differential 
blood^count," as it is called, we can usually distin- 
guish the anaemia which is due to a parasite such as 
the ankylostoma from other forms of anaemia by the 
fact that the blood contains a larger number than in 
health of white corpuscles, which stain readily with 
a dye called eosin. 

The amount of haemoglobin also often needs esti- 
mation, and though this does not require the use 
of the microscope, it may well be described in this 
chapter in connection with the other methods of ex- 
amining blood. The principle of the different methods 
is always the same, and it consists in comparing a 
diluted specimen of the blood with certain standard 
tints which correspond to definite percentages of 
haemoglobin. This estimation is always of import- 
ance in connection with counting the number of red 
corpuscles. 

Within the last few years the estimation of the time 
which the blood takes to coagulate is also a matter 
of some importance. In the disease called Haemo- 
philia, occurring chiefly in boys, there is a very great 
tendency to bleed, the slightest cut continuing to 
bleed for a long time after it should have stopped. 
Extracting a tooth in these patients (" bleeders," as 
they are called) is often followed, by haemorrhage which 
does not cease spontaneously, and can only be made 
to stop with the greatest trouble. Haemophilia occurs 

61 



The Microscope in Medicine 

in families, and when its presence has been recognised, 
no operation, even the slightest, should be performed 
unless it is absolutely essential to life. In these boys 
it has been found that the coagulation time of the 
blood is much increased. There are several methods 
of ascertaining the time taken for coagulation, and 
the simplest is to have a series of fine capillary tubes 
filled with blood, and to determine when clotting 
begins by blowing the contents of a tube on to a 
piece of filter paper at intervals, say, of a minute. 



62 




C. Crystals from the Blood of the Horse 
D. Crystals from the Blood of the Squirrel 

These are six-sided plates, of a shape often used for tiles. 



CHAPTER VI 

THE MICROSCOPE IN MEDICINE {continued) 



Bacteriology 

In the chapter on Germs a general account was given 
of these minute organisms, but little was said as 
to the practical details of recognising the different 
varieties. In this chapter will be found a description 
of the science of bacteriology as applied to medicine. 

The number of germs known is very large, but 
only some of these affect the human body, and there- 
fore it is with these we are chiefly concerned. Even 
in health many germs are present ; on the surface 
of the body are to be found large numbers of micro- 
organisms of several kinds, and some occur so regu- 
larly that it may almost be said they are normal 
inhabitants of the human skin ; they are not com- 
pletely removed by ordinary washing, and special 
precautions require to be taken if it is wished to 
obtain any part of the skin perfectly free from them. 

In the mouth also may be found, even in perfect 
health, many varieties of bacteria. It is clear, there- 
fore, that the mere presence of an organism in the 
body cannot be taken as a proof that the body is 
suffering from disease caused by that organism. In 
the mouth in health can often be found the germ 
that causes pneumonia, and on the surface of the 
skin can usually be discovered those which give rise 

63 



The Microscope in Medicine 

to boils and abscesses. Part of this absence of 
disease, in spite of the presence of the organism, is 
doubtless to be ascribed to one or more of those 
protective influences which will be found mentioned 
in the chapter on Immunity ; and if the tissues are 
healthy the germ is unable to grow freely, and awaits 
the time when, by some local damage, or in some 
other way, the tissues will become vulnerable to its 
attacks. 

If, then, the patient is suffering from some disease 
which we believe to be microbic in origin, how will 
the bacteriologist proceed in order to settle the 
question ? 

In the first place he will endeavour to examine 
microscopically some of the fluid of the part affected. 
If there is a secretion from the nose which is sus- 
pected to be the result of a micro-organism, he will 
take a small quantity of it and make a u film prepara- 
tion " as described in the chapter on the " Microscopic 
Examination of the Blood.'' 1 This film is extremely 
thin, and it is dried so as to fix it firmly to the glass 
slide on which it is made. It can then be stained 
in the manner which is most likely to show what 
is looked for, or several films can be made, and a 
different method of staining applied to each. 

In this way it may be seen that some organisms 
are present in small or large numbers, which can 
readily be recognised at sight, and stained with a 
suitable dye. On the other hand it is not improbable 
that the smear may only show a few micro-organisms 
which are not possessed of characters sufficiently 
definite to enable them to be recognised. In that 
case it will be necessary to make a " culture," or even, 
if the " smear preparation n gives us fairly certain 

6 4 




E. Crystals from the Blood of the Goose 

The blood crystals of birds show as great differences between the various 
species as do the crystals of mammals. 

F. Crystals from the Bi.odd of the Guinea Pig 

These blo^d crystals are mainly thrse-sided pyramids. 



The Microscope in Medicine 

information, a culture may serve to confirm this. 
A " culture " has several uses ; sometimes, although 
the individual micro-organism, as seen through the 
microscope, may look very much like other micro- 
organisms, yet when it is grown in a culture it may 
exhibit characteristics which serve to differentiate it. 
Secondly, by means of a culture it is possible to 
obtain a very large number of the germs and to study 
them fully, and the mere fact that an organism re- 
quires certain conditions to be observed before it 
grows in a culture, will often afford us valuable 
information as to its identity. Lastly, a culture is 
one of the necessary steps in the preparation of a 
" vaccine, 1 ' as described in the chapter on Immunity. 

By a " culture " is meant a cultivation of a micro- 
organism in a certain material which is suitable to 
its growth. This is called the " culture medium." 
Some culture media are liquid, such as broth (made 
of various meats, either unmixed or containing other 
substances), milk, the serum of blood, and some 
artificial liquids, especially Pasteur's Fluid. Most 
culture media are, however, solid : a preparation of 
gelatine called nutrient gelatine is very convenient, 
but it is liable to liquefy in very hot weather, or if 
incubated at a high temperature. Agar-agar is con- 
venient ; this is a preparation of li Ceylon moss," and 
has the merit of remaining solid at all temperatures. 
There are various forms of Agar-agar, according to the 
substances which are mixed with it, such as maltose 
agar when mixed with a form of sugar. Potato is 
sometimes a convenient medium. These culture 
media are kept in glass vessels of various kinds. The 
commonest form is a test-tube such as is used in 
chemical work, and in it the culture is placed and 

65 E 



The Microscope in Medicine 

the mouth is closed with a plug of cotton-wool ; and 
it has been shown by experiment that this cotton- 
wool is quite capable of preventing germs from out- 
side entering the tube. Both before being placed 
together, and after, the culture medium, the test- 
tube, and the cotton-wool are sterilised, and they 
are then usually tested by being kept at a suitable 
temperature to see if any micro-organism will grow 
in the tube. If any growth does appear, that tube 
was evidently not aseptic, and it is rejected. 

When a tube has been proved to be free from germs 
by this test, it is necessary to inoculate it with the 
germ we wish to grow. If it is a germ whose likes 
and dislikes we do not know, it is generally advisable 
to take several culture tubes containing different 
media, and these are all inoculated, so that we shall 
probably be able to obtain at least one satisfactory 
culture. In inoculating a tube it is essential to take 
the utmost care that micro-organisms other than 
those we are interested in do not gain access to the 
test-tube. To transfer the germs to the test-tube a 
platinum loop is generally employed. This is made 
of a piece of platinum wire fixed in a glass rod ; and 
the end of the wire is turned back so as to form a 
loop ; and first of all a good portion of the wire is 
held in a flame of a Bunsen burner or a spirit lamp, 
until it is red-hot. That method ensures the destruc- 
tion of any germs that were previously on it. 

Then the platinum loop is made to touch the surface 
from which the germs are to be taken, and a small 
quantity of the fluid is transferred to the test-tube ; 
and deposited on the surface or in the interior of the 
culture medium. For this purpose the cotton plug 
at the mouth of the test-tube is taken out and re- 

66 



The Microscope in Medicine 

placed as rapidly as possible so as not to allow any 
extraneous micro-organisms to gain entrance. The 
test-tube, thus inoculated, has to be kept at a uniform 
temperature suitable to the organism present. The 
majority of germs harmful to the human body grow 
best at the temperature of the body, that is, a little 
below ioo degrees Fahrenheit. However, others 
require a lower temperature, and about 70 degrees 
Fahrenheit is convenient. To maintain the culture 
tubes at either of these temperatures an " incubator " 
is required, which resembles in many respects the 
incubator used for the hatching of eggs, and like it 
possesses an automatic arrangement which, by con- 
trolling the supply of gas, maintains the temperature 
at a uniform level. After a time, in some of the tubes, 
if the conditions, such as the nature of the culture 
medium, and the temperature of the incubator, have 
been favourable, a spot or mark will appear on the 
surface of the medium showing that the growth of 
some germ has commenced. It often happens that 
the naked-eye appearances of this growth are suffi- 
cient to enable the bacteriologist to come to a trust- 
worthy decision as to the nature of the organism 
present. For the characters of the growths vary ; 
the colour is often of value ; the way in which it 
spreads is also of importance, and sometimes the 
appearance of bubbles of gas or the liquefaction of 
the medium will provide clues to the identification 
of the microbe. Often, however, it will be necessary 
to remove the organism from the medium, and to 
examine it microscopically with or without staining 
before arriving at a conclusion as to its nature. 

When several tubes containing different media 
have been inoculated at the same time, it is prob- 

67 



The Microscope in Medicine 

able that only some of them will manifest any 
growth. 

Not infrequently it will happen that the drop of 
fluid which the loop of platinum wire has implanted 
on the medium contains, not only one organism, but 
two or even more. In such a case the growths in 
the culture tubes may show that more than one 
organism is present, because two growths of obviously 
different appearance manifest themselves. Hence it 
will be possible for the bacteriologist from such a 
tube to inoculate a fresh tube with one or other of 
the organisms present according as he may wish. 
Even when two germs have been inoculated in the 
tube it does not necessarily follow that both will 
grow, for the conditions may be favourable to one 
and unfavourable to the other. 

In the chapter on Immunity will be found a de- 
scription of the preparation of vaccines from any 
special germ, and I have there explained that a 
vaccine prepared from the patient himself is often 
more efficacious than a "stock" vaccine, that is 
to say, one which is kept ready-made. 

Bacteriology is sometimes of very great importance 
in diagnosis. I will give an instance. Diphtheria is 
a disease due to a germ called the diphtheria bacillus, 
and it manifests its presence by the appearance of 
patches of u false membrane " generally on the tonsils 
or palate. In some cases it is easy to recognise 
diphtheria by the naked-eye appearances of the 
patches in the throat, but many doubtful cases occur, 
and it is useful or even necessary to utilise the bac- 
teriological test. A swabbing from the throat of the 
patient is rubbed over the surface of some blood- 
serum in a test-tube. This is then incubated at a 

68 



The Microscope in Medicine 

temperature just under ioo degrees Fahrenheit for 
eighteen to twenty hours, and the growth is then 
examined microscopically, after it has been stained, 
and then it is easy to recognise the germ. The 
diphtheria bacillus is a good example of the effect 
of a culture medium on the characters of the bacillus. 
In broth the diphtheria bacillus is short and stunted ; 
on blood-serum and on gelatine it is of medium length ; 
while on glycerin-agar it is very large. It is best 
stained with a special dye of methylene blue. 

In doubtful cases, especially in those which are 
mild, this method of diagnosing diphtheria is of very 
definite assistance. Now these doubtful and slight 
cases are the most dangerous, because the patient is 
not ill enough to be in bed, but he is quite well 
enough to go about and infect others. Therefore, 
in all doubtful cases, in fact in any case in which 
there is the least doubt, the diphtheria bacillus should 
be looked for bacteriologically, and this method of 
examination is also of great value in deciding the 
question whether and when it is safe for the patient 
to mix with others. So long as the special bacilli 
can be found in the throat by this method of ex- 
amination, so long is it clear that infection of others 
is possible ; therefore a child who has had diphtheria 
should not be allowed to mix with his fellows until 
the bacteriologist reports that by this test no bacilli 
have been found to be present. Usually it takes 
about three weeks for the diphtheria bacilli to dis- 
appear from the throat, but sometimes they remain 
much longer than this, even for months. It is clear 
that while a positive result of the bacteriological test 
of the presence of diphtheria bacilli is of the greatest 
value, a negative result is worth much less, for the 

6 9 



The Microscope in Medicine 

swab may have failed to bring any out though they 
were present ; therefore sometimes if the test is 
negative it may need to be repeated. 

A bacteriological test known as u WidaFs Reaction " 
is of great value in the diagnosis of typhoid or enteric 
fever. A few drops of blood are taken from the ear 
or finger of the patient and are drawn into a capillary 
tube and sealed, so as to be ready for the test. A 
recent culture of the typhoid bacillus in broth is 
employed, and ten drops of it are taken and mixed 
with one drop of the serum of the patient. The 
mixture is then examined under the microscope for 
half-an-hour. The typhoid bacilli which were moving 
freely before, become quickly still when mixed with 
the patient's serum. In a few minutes the bacilli 
begin to mass together into clumps, and by the end 
of half-an-hour the clumping is complete. If the 
clumping occurs it is almost certain proof that the 
patient is suffering from typhoid fever, but the test 
certainly fails sometimes even though typhoid fever 
is present. 

Bacteriology is of immense value in controlling 
the water supply of a town. The chemical examina- 
tion of drinking water will give us much information 
as to contamination with sewage, but it tells us nothing 
as to whether the germs of disease like typhoid are 
present or not. 

The bacteriological examination is of the greatest 
possible importance in this respect. 

In examining a specimen of water for its bacterial 
constituents, a specimen is taken in an aseptic bottle. 
It is important that it should be examined as quickly 
as possible, for if it is allowed to stand for long the 
number of bacteria present may increase greatly, and 

70 



The Microscope in Medicine 

forty-eight hours of delay may make a difference of 
many thousands in the number of bacteria present. 
If it is quite impossible to examine the specimen 
within a short time of its being taken, it should be 
kept in ice, for the cold will practically prevent the 
multiplication of the germs. To find the number of 
organisms present, four culture tubes containing gela- 
tine are taken, and they are inoculated with different 
measured quantities of water. After the water and 
the gelatine have been mixed together the contents of 
each tube is poured out into a flat, shallow dish, called 
a " Petri dish," which has a glass cover to protect it 
from extraneous organisms. These dishes are in- 
cubated at a temperature of 70 degrees Fahrenheit 
for a week, and at the end of that time they are 
examined. Every germ which has developed will 
have formed a little colony visible to the naked eye, 
and if these colonies are counted, it is easy to calcu- 
late the number of germs present in any volume of 
water. If only a few germs were present in the water, 
it will be easy to count them in that specimen to 
which the larger quantity of water has been added, 
but if many germs were present this specimen might 
show so many colonies that it might not be possible 
to count them, and therefore a specimen with a 
smaller quantity of water might give more satis- 
factory results. 

If a cubic centimetre of the water contains not 
more than five hundred organisms it may be described 
as fairly good. A very good water indeed will con- 
tain less than one hundred. 

If it is desired to look for any special organism, 
special methods would have to be employed for that 
purpose. 

7i 



The Microscope in Medicine 

Although the number of organisms present cannot 
be a certain guide as to the value of the water for 
drinking purposes, yet it affords valuable assistance 
in estimating the fitness of the water for drinking. The 
filtration of water to serve for the supply of a town 
is generally carried out by means of a sand filter bed. 
This works much better after a short time than at 
first, and it has been found that the real filtering 
medium is a layer of mud which gets deposited in 
the interstices of the sand. When a new filter bed is 
freshly made the effluent contains many more micro- 
organisms than it will contain a fortnight later. 

The most remarkable discovery that has been made 
in recent years in connection with the water supply of 
towns is the diminution in the bacterial element in 
water on keeping. When water is allowed to flow 
into a reservoir and there remain still, the number of 
bacteria in it steadily decreases, so that after a few 
weeks it has become a much more suitable water for 
drinking purposes than at first. This fact renders it 
very desirable that there should be several large reser- 
voirs in connection with the water supply of towns, 
so that it would not be necessary to use the water 
until after it had stood for several weeksT^ 



72 



CHAPTER VII 

THE MICROSCOPE IN MEDICINE (concluded) 

Microscopic Examination of Tissues 
and Tumours 

It is possible in some cases to recognise the nature 
of a tumour by the naked eye, so that the surgeon 
can be certain that it is harmless, but this he cannot 
always do. Many tumours are so much alike when 
examined by the unaided vision that a satisfactory 
conclusion can rarely be based on what has been 
seen, therefore it becomes necessary to employ a 
more certain method of investigation. 

To use the microscope in the examination of solid 
substances like the tissues, it is necessary that they 
should be in very thin sections ; otherwise they are 
not translucent and cannot be clearly examined. 
Most tissues are too soft as they are taken from the 
body for sections to be made from them, and there- 
fore it is necessary to make them firmer, or to 
"harden" them as it is called. They must not be 
made too hard, otherwise the knife will not be able 
to cut a very thin section. Many liquids are used for 
hardening, such as alcohol and a solution of chromic 
acid, different reagents being employed according to 
the tissue which is to be examined. These hardening 
reagents also serve as antiseptics and prevent decom- 
position. A piece of the tissue is taken ; it must not 

73 



The Microscope in Medicine 

be too big or it will not harden well, a piece about 
three-quarters of an inch in diameter is a common 
size, and it is put into the hardening fluid. After 
immersion in one or more of these liquids for a 
longer or shorter period as experience has shown to 
be necessary, the small mass of tissue is ready to be 
cut into sections ; but before this can be done it must 
be fixed firmly, or embedded, as it is called, so that 
it may be held firmly before the section knife is 
applied to it. 

The simplest and quickest method is to freeze the 
mass of tissue after surrounding it with gum. Some- 
times it is necessary for the surgeon to learn the 
nature of a tumour in the middle of an operation so 
that he may know the best course to pursue. The 
freezing method is therefore especially useful in these 
circumstances, as it takes so little time. By the 
freezing method perfectly fresh tissues can be cut 
without undergoing any previous hardening. Though 
this method is very quick, and therefore may be used 
when time is of importance, the results on the whole 
are not so satisfactory as when another method is 
employed. In this second method the tissue is placed 
in the middle of melted white paraffin, such as 
paraffin candles are made of, or any other similar 
substance may be employed. When the paraffin has 
become quite cool and solid the section cutting may 
begin. For cutting sections many instruments have 
been invented, but in principle they are all the same. 
A very sharp razor is brought across the mass of 
tissue, and each time it passes, the tissue is raised a 
very short distance by means of a fine screw so that 
extremely thin slices of the tissue are cut. In some 
instruments the knife moves ; in others the knife is 

74 



The Microscope in Medicine 

fixed, and the tissue is brought to it for each section. 
In this way sections can be cut less than the 
thousandth of an inch in thickness. Even when 
satisfactory sections have been cut, it is not possible 
to learn much from them by the microscope in their 
present state, and they require staining. 

I have already said that we distinguish the different 
kinds of white corpuscles by the different ways in 
which they receive stains ; it is in the same way that 
we are able to distinguish different tissues from one 
another. Various stains are employed ; most of them 
are made from aniline dyes. A little of the stain is 
put into a watch-glass or other shallow dish, and 
one or more of the sections are immersed in the 
liquid for a longer or shorter time. In this way 
certain tissues seize certain stains, while others are 
affected by other dyes. It is necessary to employ 
other solutions for fixing the stain in the tissues and 
for making them more transparent or " clearing " 
them. When the staining and clearing are com- 
plete, the section is carefully spread out on a micro- 
scopic slide and then on it is placed a drop of 
some form of cementing substance, and over it is 
placed a very thin piece of glass, called a "cover 
glass." 

The section is then ready for examination under 
a microscope. Now the structure of the tissue 
can be seen. The cells and fibres of which it is 
composed are clearly discernible, and by the colours 
with which the different portions of it have been 
stained we can tell something of their chemical com- 
position. For instance, if osmic acid has been em- 
ployed in the stain, any fatty substance present will be 
coloured black. In this way it is possible to obtain, 

75 



The Microscope in Medicine 

in most cases, a very exact idea of the structure and 
nature of the tissue examined. 

If it is thought that bacteria are present in the 
tissue and it is desired to examine them, it will be 
necessary to employ stains which will colour them ; 
and in this way also we can distinguish different 
bacteria. In the tissues many bacteria show little 
difference in appearance. Occasionally by the size 
or the shape of a microbe we can recognise it, but 
more commonly we have to employ certain stains 
to assist us in the recognition of the germs. Some 
bacteria will take a particular stain while others will 
not. 

It is sometimes convenient not only to stain the 
bacteria but also to stain with a different colour the 
tissues in which the bacteria lie. This will generally 
give very striking effects, and it makes the bacteria 
much more visible. 

Fresh stains are frequently introduced giving re- 
sults which could not be obtained before, and helping 
us to know with greater certainty the nature of the 
tissues examined. 

In 1889 influenza reappeared in Great Britain for 
the first time for forty years. When it was prevalent 
before, bacteriology as a science did not exist, and 
therefore nothing was known as to its bacteria. On 
its return film preparations were made, but none 
of the stains then employed showed any special 
organisms, but the slides were put aside. The next 
year Pfeiffer found a stain that showed the bacillus 
of influenza, and when this stain was tried on the 
slides which had been prepared in the previous year, 
the bacillus was readily seen. 

76 



CHAPTER VIII 

IMMUNITY 

It is well known that many infectious diseases which 
attack one class of animal may not have the least 
effect on animals belonging to other species. Most 
of the infectious diseases to which man is liable do 
not appear to be communicable to the lower animals ; 
it is also true that most of the infectious diseases to 
which races of the lower animals, such as cattle, 
sheep, or dogs are subject, do not attack human beings. 
When the most virulent pestilences have been raging 
through large communities, as a rule none of the 
domestic animals have shown any sign of being 
affected. Neither scarlet fever nor measles has been 
known to invade any of the animals which come in 
contact with man. When, in 1897, the rinderpest was 
killing hundreds of thousands of cattle in South 
Africa, not a single human being showed at any 
time the slightest trace of an attack of the malady. 
In those regions of Africa where the tsetse fly disease 
attacks all horses except those which are "salted," 
that is, those which have already had an attack of 
the disease, man is not affected. The rule that 
human beings and animals are not attacked by the 
same infectious disease is by no means absolute, 
and as an instance it may be mentioned that rats 
suffer greatly during an epidemic of plague. 

This freedom from liability to catch a disease is 

77 



Immunity 



called "immunity/' and it is of two kinds. The form 
of immunity with which a person is born is called 
" inherited immunity," and it is that form which I 
have described above, and which is possessed by 
all the members of a race. 

There is, in addition, another form of immunity. 
When a man has had an attack of scarlet fever, there 
is no real risk that he will take it again, however 
much he may be exposed to infection. I cannot say 
that infection in such a case never occurs, for in- 
stances are occasionally reported in which a person 
who has had one attack of scarlet fever is said to 
have a second attack. It is probable that in some 
of these cases an error of diagnosis has been made, 
but there are certainly some, a few, a very few cases, 
in which a second attack of scarlet fever occurs. 
Nevertheless, the general law holds good that for 
all practical purposes a person who has had one 
attack of scarlet fever cannot be reinfected, and this 
is true also of most of the other acute infectious 
diseases. This freedom from liability to contract a 
disease, possessed by those who have suffered from 
it, is another form of immunity, and it is called 
"acquired immunity." This fact that an attack of 
most of the acute infectious diseases affords pro- 
tection against a second attack has been recognised 
everywhere for many centuries, and attempts have 
been made to utilise it. Inasmuch as many of these 
diseases attack more easily those who are weak and 
out of health, it was thought that if the disease could 
be given when the patient was in good health the 
attack would in all probability be milder, and less 
likely to prove fatal. This method was used for 
smallpox, and it was called "inoculation." Though 

78 




u ° 

£ I 

' in 

2 1 

< -5 




a 
"!7j tj 




Immunity 

it fulfilled the expectation of those employing it, in 
that it caused a comparatively mild attack of the 
disease, yet the contagiousness of the smallpox was in 
no wise lessened, and those inoculated patients were 
often so little ill that they were not confined to bed 
but mingled with their fellows, with the result that 
although the patient himself benefited, the disease 
tended to spread. 

I have described elsewhere the introduction of vac- 
cination for smallpox by Edward Jenner, and here I 
need say only that this was the first attempt to employ 
a weakened virus (or " attenuated virus " as it is gener- 
ally called) for the purpose of preventing an attack 
of a disease, and it is now recognised that an attack 
of a disease produced by an attenuated virus is in most 
cases as effective in preventing a second attack as is 
the disease itself ; thus vaccination is as effective in the 
prevention of a subsequent attack of smallpox as is 
inoculation. 

The virulence of germs can be altered in many 
ways ; by heat, by the conditions of growth, or by 
passing the germ through the body of another animal. 
In the case of vaccination for smallpox the virulence 
of the germ of the disease is greatly weakened by 
passing it through the cow, so that, when it is in- 
troduced into the human body, it is no longer capable 
of causing a severe attack of the disease, but it pro- 
duces instead a very mild affection which manifests 
itself only by a few vesicles. Yet, though the in- 
fection produced in man is so slight, it confers an 
" immunity" practically as potent as would have 
been conferred by an attack of smallpox. 

The next great step was taken some eighty years 
later, when Pasteur was investigating the disease of 

79 



Immunity 

fowls which is known as "chicken cholera." He 
discovered the germ which caused the disease, and 
whilst he was studying the effect of its introduction 
into fowls he found that if the cultures of the germ 
were old, the symptoms produced when the germ 
was inoculated into a fowl were mild, and the bird 
did not die ; and further, that if the same fowl was 
afterwards inoculated by some fresh culture, it did 
not die, although the same culture would kill rapidly 
an unprotected bird. This was a most important 
step, for it showed one way of weakening a germ 
so that it might be used to vaccinate a " susceptible 
animal," and thus protect it from an ordinary attack 
of the disease. In France chicken cholera had pre- 
viously caused the death of about 10 per cent, of the 
fowls, yet after Pasteur's discovery less than i per 
cent, died from the disease. 

The next malady studied by Pasteur was anthrax. 
This is a serious disease, which is liable to affect 
sheep and cattle. It was endemic in France, especi- 
ally in the marshes of Sologne, Bresse, and Dombes. 
At irregular intervals it would spread from centres 
such as these into other districts, and the total loss 
of animals was very great. The disease can attack 
man, but this is rare. 

Pasteur proceeded to search for an exact method 
of obtaining an attenuated virus. It had already 
been found that a short heating to a high temperature 
of a liquid containing anthrax bacilli certainly at- 
tenuated the bacilli, but it was difficult to use this 
method and ensure that the result was what was 
desired. Pasteur showed that the best method was 
to grow the anthrax bacilli at a temperature of 108 
Fahr. At this temperature, which is much above the 

80 



Immunity 



"optimum" temperature for the bacilli, they grow, 
but no spores are formed, and the bacilli become 
much weakened in virulence. These attenuated 
bacilli he inoculated into cattle and sheep, and they 
became immune, and thus he was able to protect 
them against infection. The effect of the introduc- 
tion of this method of vaccinating cattle and sheep 
against anthrax was very great. Millions of animals 
in many parts of the world have been rendered im- 
mune by this method, and the loss from this disease 
is less than one-tenth of what it was before the 
introduction of Pasteur's method. Soon after the 
publication of this method French insurance com- 
panies declined to insure the cattle and sheep in 
districts infected with anthrax unless they had been 
treated by Pasteur's inoculation. 

The next problem which Pasteur endeavoured to 
solve concerned Rabies. This disease manifests itself 
mainly in dogs, but it may also occur in cats, deer, and 
several other races of animals. When it attacks man 
it is usually called Hydrophobia, and it results from 
the bite of a rabid animal. The disease is usu- 
ally so rare that any vaccination against it, in the 
meaning of the word as applied to small-pox or 
anthrax, is for most people quite unnecessary, and 
therefore it is useless to attempt to devise any such 
method. As the incubation period of the disease 
(that is, the time after infection before symptoms 
appear) often amounts to months, it occurred to 
Pasteur that it might be possible, by means of an 
attenuated virus, to protect from the disease persons 
who had already been bitten by an animal suffering 
from rabies. It will be seen that the success of this 
method depends on the possibility of the attenuated 

81 F 



Immunity 



virus acting more rapidly than the germs which were 
introduced by the bite. One difficulty was, that 
nothing was known of the germ causing the disease, 
in fact it was not even known certainly that it was 
caused by a germ ; though the communicability of 
rabies left little doubt on the point. It would take 
too long to describe in full the various methods which 
Pasteur employed ; suffice it to say that he found 
that the poison was situated in the spinal cord ; for 
if a portion of the spinal cord of an animal suffering 
from rabies is injected into a susceptible animal the 
disease will show itself rapidly and quickly prove 
fatal. If the spinal cord of a rabbit which has been 
affected with rabies is removed from the body and 
allowed to dry, its virulence diminishes, and the 
longer the spinal cord dries, the weaker is the poison 
it contains. In this way he was able to obtain a 
virus of any desired strength, and he found it possible, 
by commencing with a very weak virus and gradually 
increasing the strength, to " vaccinate " animals who 
had been bitten by a rabid animal so as to prevent 
the disease appearing. 

An extension of the method to man proved equally 
successful, and in most countries of the civilised 
world Pasteur Institutes have been erected to deal 
with cases in which it is probable that hydrophobia 
would arise. It is somewhat difficult to give statis- 
tical proof of the benefit of the Pasteur method of 
dealing with hydrophobia, for not every person 
bitten by a rabid dog develops hydrophobia, but 
of those bitten on the bare hands or face very few 
indeed escape, and in cases in which hydrophobia 
has manifested itself recovery is almost unknown. 
When, however, the Pasteur method is employed 

82 



Immunity 



within a short time of the bite, the death-rate is 
under one per cent., so that we are fully justified in 
thinking that a very large number of lives are saved 
by the use of the method devised by Pasteur. 

In all the instances which I have described it is 
evident that, by means of microbes, weakened in 
virulence in one way or another, we have been able 
to obtain an acquired immunity analogous to that 
form of immunity which follows, in many cases, an 
ordinary attack of an acute infectious disease. 

The question that now calls for solution is, u What 
is the nature of this immunity, and how is it brought 
about ? " 

At one time it was thought that the reason why 
a person who had had one attack of a fever, such 
as measles, could not be infected a second time, was 
that the germs had fed upon some substance in the 
patient's body, and had exhausted the supply so that 
it could no longer exist there, as this substance neces- 
sary for its life was no longer provided. This, which 
has been called the "pabulum" theory, is now no 
longer held. The arguments against it are many. 
In the first place, as an attack of one infectious 
disease does not protect against an attack of another 
infectious disease, it must follow that there is a 
"pabulum" for each form of microbe. Secondly, 
persons who have recovered from any of these 
diseases are, in nearly all cases, as well as they were 
before ; from this fact it would follow that these 
various forms of pabulum are not at all necessary 
for the life, or even for the well-being of the person, 
so it would appear that the only possible reason for 
the existence of these pabula would be that they 
might provide food for the various infective microbes. 

83 



Immunity 

We have only by a long course of investigation 
arrived at our present knowledge of the mode in 
which a living body becomes "immune"; and even 
now, after researches in all civilised lands by hundreds 
of investigators, there are many obscure points and 
many unsolved problems. A description of the pro- 
gress of the investigation should prove of interest. 

More than thirty years ago, it was shown by Traube 
that if a small quantity of putrefying material was 
added to some shed blood, the blood possessed the 
power of remaining sweet, and from this fact it was 
argued that blood must possess a certain power of 
destroying germs. It had then to be settled whether 
this bactericidal power resided in the blood corpuscles 
or in the liquid part of the blood. Metchnikoff, of 
Paris, was the first to lay stress on the part played 
by the white corpuscles of the blood in the destruc- 
tion of bacteria, and it will be worth while to under- 
stand how they do it. 

In many stagnant pools and ditches and elsewhere 
may be found a small animal called the amoeba. 
This holds a very low position in the scale of Nature, 
and is, in fact, almost one of the lowest of animals. 
It is microscopic in size, measuring about y^ of an 
inch in diameter ; it consists of a minute mass of a 
jelly-like substance called " protoplasm," and em- 
bedded in the middle of it is an oval body called the 
nucleus. This little animalcule can move from place 
to place, but very slowly, and it does it by putting 
out projections from one or other side of its body, 
and then the rest of the body flows after the pro- 
jection. If on its way it meets with a small solid 
body it surrounds it and so takes it into itself. If 
the included particle is nutritious, it is slowly dis- 

8 4 



Immunity 



solved and disappears, and thus the amoeba is sup- 
plied ,with food. The manner in which this is done 
is clearly shown in the illustration. 

It is worthy of note that one form of dysentery 
is due to an amoeba. 

I have described the amoeba, and its mode of taking 
food, because the animal can be readily obtained and 
examined by any one who possesses a microscope, 
and because its method of feeding is almost exactly 
similar to the way in which the white corpuscles of 
the blood destroy bacteria. 

The blood consists of a liquid part, the u plasma," 
as it is called, and a very large number of minute 
bodies called corpuscles ; most of these are coloured, 
and are called the red corpuscles, but some are 
white ; and these white corpuscles are wonderfully 
like amoebae. They have the same general structure ; 
like amoebae they can wander slowly from place to 
place, and like amoebae they can engulf any small 
objects with which they meet ; but in one point 
there is a great difference between them, and that 
is in size. An amoeba may measure yig- of an inch, but 
a human white corpuscle is only about arVs °f an 
inch in diameter. The white corpuscles of the blood 
are carried along with the blood-stream, but in 
addition they can wander about, clinging to the walls 
of the arteries and veins, and even, when inflamma- 
tion is present, passing through the walls of the 
smallest blood-vessels. In their wanderings white 
corpuscles may meet with bacteria, and then the 
corpuscle swallows one or more of the germs just 
as the amoeba swallows its food, and the germs can 
be seen lying within the body of the white corpuscle. 
After a longer or a shorter time it may be seen that 

8 5 



Immunity 



the outlines of the bacteria become less distinct, and 
gradually the bacteria are dissolved. The number 
of bacteria swallowed by a single white corpuscle 
may be very great ; in fact so many may be taken 
that they appear to occupy the whole of the cor- 
puscle. 

In this way it is certain that in the living body 
large numbers of bacteria which have intruded into 
the blood stream are swallowed and destroyed by the 
white corpuscles of the blood, and Metchnikoff named 
these corpuscles which can devour bacteria the 
"phagocytes" or eating-cells. It is, however, by no 
means certain what degree of importance is to be 
attached to the action of the phagocytes ; Metchnikoff 
considered this process (which is called " phago- 
cytosis ") the most important means possessed by the 
body for combating invading bacteria, while other 
authorities look upon it as of minor importance. It 
is impossible, with our present knowledge, to decide 
between their opinions, but it is at least absolutely 
beyond dispute that when bacteria do enter the blood 
stream very many of them are swallowed, digested, 
and so destroyed by the phagocytes. 

The outcome of the fight between the phagocyte 
and the microbe is not always so fortunate as I have 
described above. Sometimes it happens that the 
phagocyte has been weakened by previous ill-health, 
sometimes the assaulting bacteria are either more 
numerous or more virulent than usual, and then, 
instead of the swallowed germs being digested, they 
destroy the phagocytes that venture to swallow them, 
and they emerge from the combat stronger even than 
they were before. 

It has been shown by careful experiment that it 

86 



Immunity 



sometimes happens that when a disease-germ attacks 
a person for the first time the phagocytes of his blood 
prove to be unskilful in dealing with it, for they are 
unable to swallow many of the germs ; later it is 
found that the phagocytes have learned by experience 
and are then much more capable of fighting the 
invaders. We do not know the process by which is 
brought about this " education " of the phagocytes, as 
it has been called, but that it occurs there is little 
doubt. 

Another very curious fact about phagocytes is that 
there exist in the plasma of the blood certain sub- 
stances which have the property of making bacteria 
more readily attacked by the phagocytes. These 
substances are called u opsonins," because they pre- 
pare the bacteria to be eaten, for the word comes 
from a Greek verb meaning " to provide with food." 
We do not know much about opsonins ; we only 
know that when they are present in large quantities 
the phagocytes feed greedily on the bacteria, but 
when they are scanty the phagocytes take the bacteria 
far less readily. These opsonins are of no little 
importance nowadays, both in the diagnosis of 
obscure infective diseases and in affording indica- 
tions for their treatment. 



87 



CHAPTER IX 

IMMUNITY {continued) 

Thus we see that the white corpuscles of the blood 
are actively concerned in the destruction of the 
bacteria which invade the blood, and that they are 
aided by certain substances, called opsonins, in the 
plasma of the blood which prepare the bacteria for 
the attacks of the phagocytes. Natural immunity, 
then ; is due in part at least to phagocytosis, but 
important though the phagocytes and the opsonins 
are in this matter there are other factors of even 
greater importance in the causation of immunity, and 
these exist in the liquid portion of the blood. It 
would be merely confusing to the reader if I were 
to enter even briefly into a description of our reasons 
for thinking that there are various substances in the 
blood which are antagonistic to bacteria ; here it will 
be sufficient to say that there are such substances, and 
that they possess the power either of destroying the 
bacteria directly (and not merely indirectly like the 
opsonins) or of neutralising the toxins or poisons 
produced by the bacteria. These are all conveniently 
included under the term " antibodies/' As mentioned 
above, some of these antibodies act directly on the 
bacteria, killing them or at least preventing their 
multiplication, while the action of others is limited to 
neutralising the poisons which the bacteria form. 
These antibodies in some cases exist naturally in 

88 



Immunity 



the human body, but in other cases they do not 
appear until the body has been attacked by bacteria, 
and then they are developed by the body as a result 
of the stimulus supplied by the invading germs. To 
make clear this matter, so far as possible, I will 
describe what occurs in a simple case. 

Many animals secrete poisonous substances which 
they can, at will, inject into their enemies, and these 
poisons are called their ll venoms." Poisonous snakes, 
scorpions, some spiders, toads and salamanders may 
be mentioned as examples. In the venoms formed 
by these animals there are no germs, but they contain 
chemical substances, most of which are of extreme 
virulence. Some snake venoms are so potent that 
it has been calculated that a quarter of a drop is 
sufficient to prove fatal to a man within a short time. 
We may compare such a venom to the toxins pro- 
duced by bacteria, and it will be instructive to consider 
how an antidote to snake venom can be obtained. It 
does not appear that the animals which habitually 
attack snakes, such as the mongoose and the secretary- 
bird, possess any natural antibodies so that they might 
be bitten with impunity, for they seem to depend for 
their safety on their agility. If a series of very small 
quantities of snake venom (very, very much less than 
would prove fatal) be injected at intervals into an 
animal such as a horse, it will be found, after a time, 
that when a poisonous dose is subsequently adminis- 
tered, the animal does not die, and in fact seems 
none the worse for the dose that would have killed 
it, if it had not been protected. This immunity is 
found to be due to certain substances, " antibodies" 
as we may term them, in the blood of the animal, 
and if some of the animal's blood be obtained, and 

8 9 



Immunity 

the liquid part or " serum" separated from the cor- 
puscles and the clot, " antivenom " serum, as it is 
called, is obtained. The action of the antivenom on 
the venom appears to be purely chemical, the two 
neutralising each other, as do an acid and an alkali 
in a test-tube. If a suitable quantity of antivenom 
be mixed with a poisonous dose of snake venom and 
the mixture be injected into an unprotected animal, 
no harmful result follows. Again, if a suitable amount 
of antivenom serum be injected into an animal, and 
then, later, a poisonous dose of venom be injected, 
no symptoms are caused, for the antivenom already 
in the body of the animal has neutralised the venom 
subsequently injected. Nay more, if a poisonous dose 
of venom be injected into an animal, and then, soon 
after, the correct amount of antivenom be injected, 
in this case also the animal survives unharmed. But 
it is absolutely essential that the interval between the 
injection of the poison and its antidote should not 
be too long. If the dose of poison is such as would 
naturally kill the animal in three hours, the antidote 
must be given not later than one hour after the 
poison. Still further it has been found that if an 
animal be bitten by a venomous snake, an injection 
of the antivenom serum, administered soon after the 
bite and in a suitable amount, will avert death. 
This is not only true of animals. Since 1895, when 
Calmette first prepared an antivenom serum, many 
cases have been recorded in which the lives of human 
beings have been saved by the timely injection of the 
serum. Only too often the serum is not at hand when 
it is wanted, and the virulence of the poison generally 
precludes the possibility of obtaining the antidote in 
time to be of use. In countries where venomous 

90 



Immunity 



snakes are common, it is likely that the serum may 
be more available than where snakes are rare. In 
India there are some 30,000 deaths from snake bites 
every year ; but it is hardly possible to expect that 
in any large proportion of the cases of snake bite it 
will be possible to have recourse to curative serum. 
Nevertheless, its production is distinctly a step in 
advance in medicine. 

I have selected snake venom and the mode of 
obtaining its antidote as a simple example of the 
formation of antibodies in the animal body as the 
result of the injection of small doses of a toxin. I 
will take next an instance in which antibodies have 
been produced for the cure of a disease caused by 
bacteria. Diphtheria has doubtless existed for many 
centuries and, in fact, we have a description by 
Aretaeus of it dating as far back as the second 
century A.D., and epidemics of it appear to have 
occurred from time to time in several countries in 
Europe ; but in these earlier accounts it is probable 
that other throat affections were confused with the 
disease, and it was not till 1821 that it was clearly 
separated from other affections resembling it. The 
most decisive step was not taken till 1883, when the 
bacillus causing the disease was first clearly described 
by Klebs and Loffler. Diphtheria is a disease which 
mainly attacks the throat and windpipe, and it chiefly 
affects children, though adults are also liable to it. 
It is found in most civilised countries, but it is not 
common in the tropics. It is prevalent in this 
country, but in some foreign countries it occurs much 
more frequently. 

It is extremely contagious and occurs in epidemics, 
though single cases are not rare. It forms a " mem- 

9i 



Immunity 



brane " over the affected surface, and in fatal cases 
death is generally due to obstruction of the breathing, 
though it often happens that the fatal result is brought 
about by the poisoning effect of the disease on vital 
organs. Even when recovery follows an attack, it is 
by no means rare to find that serious sequelae have 
been left behind, and of these the most important is 
paralysis. The mortality from diphtheria has always 
been high, and formerly it varied probably between 
30 and 50 per cent. It is quite certain that diphtheria 
is due to the " bacillus diphtheriae/' and the bacillus 
causes the disease by a poison or li toxin " which it 
secretes. 

The problem of treatment was, then, not very dis- 
similar from that of poisoning by snake venom ; and 
it was solved in 1894 by Behring and Roux, who pre- 
pared an " antitoxin serum " for the treatment of the 
disease. The mode of preparation is as follows : 
A culture of the diphtheria bacillus is made by putting 
bacilli, "taken from a case of the disease, into some 
broth which is kept at a suitable temperature ; the 
bacillus grows freely and forms a toxin which mixes 
with the broth. The broth is then filtered, so as to 
obtain it free from diphtheria bacilli. This broth, 
which contains the diphtheria toxin, is then injected 
into a horse at intervals in gradually increasing doses. 
This leads to the formation of large quantities of 
antitoxin in the horse's blood. After a time some 
blood is drawn off, the clot and the corpuscles are 
separated, and the serum that remains is the " anti- 
toxin serum," which is used in the treatment of diph- 
theria. When its strength has been tested it is ready 
for injection. The earlier in the disease the serum is 
injected the more striking are its effects ; but even in 

92 




An Amoeba 

This is a low form of animal, and in shape and 
movements it resembles a white corpuscle of the 
blood. In the upper figure an amoeba is about to 
surround and swallow a minute form of plant. 



A "Culture" of Diphtheria 
Bacilli 

A culture-tube containing serum, on 
which are seen small white patches. 
These are masses of the bacilli of 
Diphtheria, which have been grown 
in an incubator. 



Immunity 



a somewhat late stage it may do good. The result of 
the use of the serum in diphtheria has been remark- 
able ; the mortality, which was rarely below 30 per 
cent., has steadily declined ; year by year it has dimin- 
ished as the use of the serum has become more wide- 
spread and as the cases of the disease have been 
treated at an earlier stage. Further, we have learned 
more as to the best dose to be given, and the quantity 
now administered is larger than at first. The death- 
rate at present is under 10 per cent., and it has been 
estimated that in London alone the lives of more than 
a thousand children are saved every year by the 
use of diphtheria antitoxin serum. Here, then, is a 
veritable triumph of modern medicine, based, not on 
properties accidentally discovered, but on observations 
carefully made and experiments accurately carried 
out. Diphtheria antitoxin is also sometimes used 
prophylactically, that is to say, to protect the healthy 
from an attack of the disease. When diphtheria has 
broken out in a household containing several children, 
it is well to treat with the antitoxin not merely those 
who manifest signs of the disease, but also the others 
who have been exposed to the risk of infection. By 
adopting this practice it has been found possible to 
stay an outbreak at the beginning. The protection 
afforded by a prophylactic injection of diphtheria 
antitoxin is not permanent ; its exact limits are not 
known, probably it does not last longer than a few 
weeks ; but even this period is sufficient to prevent the 
appearance of the disease after exposure to infection. 
This method of using the serum of artificially im- 
/ mune animals for the curative treatment of an infec- 
tive disease is, at present at least, not very widely 
applicable ; in fact the [only other disease in addition 

93 



Immunity 



to diphtheria in which it is commonly employed is 
tetanus, or "lockjaw/' as it is popularly called. 
This is caused by a bacillus with a swelling at one 
end, due to the presence of a spore, so that it has 
been named the " drumstick bacillus." This germ 
lives chiefly in mud, and therefore wounds into which 
mud has been forced are specially liable to become 
infected with it. The antitoxin serum of tetanus has 
the most beneficial effect when it is administered very 
early in the disease, and there can be no doubt that 
it may have a preventive action ; therefore many 
surgeons consider it advisable to inject some of the 
tetanus antitoxin in all cases where the likelihood of 
infection with this microbe is great. It is impossible 
from the very success of its action to prove absolutely 
that the antitoxin really does prevent the appearance 
of the disease, for it may always be said that in these 
cases no infection has occurred ; but it is recognised 
that where such prophylactic treatment is adopted, 
tetanus is never, or hardly ever seen. 

These methods of producing an artificial immunity 
by the injection of a serum containing antibodies 
produced in other animals has been aptly called 
" passive immunity/' because the body of the person 
injected has taken no part in causing the immunity. 

We come now to a more complex method of treat- 
ment of disease by means of antibodies. In the case 
of diphtheria, the broth in which a culture of the 
diphtheria germ was made contained the toxin of 
the disease, that is, the toxin is excreted by the bacil- 
lus ; but this is not the case with the germs of all 
infectious diseases. In many, the toxins formed re- 
main within the bodies of the bacteria, and therefore 
the injection of the filtered broth in which the germs 

94 



Immunity 



have grown will not give rise to any antitoxins. In 
cases such as these it is necessary to inject the bacilli 
themselves, though it is, of course, necessary to kill 
them before injecting them. The injection of this 
emulsion of dead bacilli leads to the formation in the 
body of antibodies of various kinds. The opsonins 
also are increased in amount, and altogether the de- 
fensive powers of the body are strengthened. These 
emulsions of dead bacteria have, somewhat unfortu- 
nately, been called "vaccines," for they are liable to 
be confused with the true vaccines which contain the 
germ of the disease, living but attenuated in strength 
and able to multiply in the body. 

The vaccines containing dead bacteria are injected 
into the patient, and the antibodies are elaborated by 
the patient's own body, and not, as in the case of 
antitoxic sera, in the body of another animal. The 
number of bacteria contained in a suitable dose of 
a " vaccine" may be very large, for it may amount 
to tens of millions or even to hundreds of millions. 
These vaccines have been employed in a very large 
number of diseases, and of their value no one who 
has had much experience of them can doubt ; but 
their introduction is at present comparatively recent, 
and therefore we are hardly in a position to speak 
with certainty about the value of all of them. 

As ^to several of these vaccines there cannot be 
any real doubt. For instance, it is not rare for some 
persons to be exceedingly liable to attacks of boils, 
and many of these boils are caused by micrococci. 
It has been found repeatedly that the injection of 
one or more suitable doses of a vaccine containing 
this micrococcus will be followed by the rapid dis- 
appearance of the boils. The preparation of a vaccine 

95 



Immunity 



is fairly simple. A suitable culture medium is taken 
and is inoculated with the required microbe ; this 
is incubated at the correct temperature, until the 
microbe has increased enormously in numbers. Then 
the germs are killed, and the " vaccine " is ready 
for injection. In some cases a vaccine prepared from 
an ordinary culture of the germ may be employed, 
but in other cases it seems to be essential to employ 
for the culture some of the germs obtained from the 
patient himself. 

The acquired immunity resulting from the injection 
of a vaccine is called " active immunity," because the 
patient's body itself manufactures the antibodies ; 
while, as I have mentioned already, the immunity 
produced by an antitoxin serum is called a " passive " 
immunity, because the antibodies have been prepared 
in the body of another animal. 

In all these methods we have powerful aids in the 
treatment of disease, and we may be sure that in the 
future their value will be far greater than it is at 
present. 



9 6 



CHAPTER X 

VACCINATION 

I have thought it well to deal with the subject of 
vaccination in this work, for it was certainly the 
earliest attempt to prevent disease by means of pro- 
tective methods closely allied to those which Nature 
provides. Vaccination is, moreover, typical of one 
mode of dealing with bacterial infection which is 
being employed widely at the present time. 

Before we can appreciate fully the advantages 
which have been gained through vaccination, it is 
necessary that we should have a clear idea of the 
conditions which existed in this country when small- 
pox was uncontrolled. The disease was first recog- 
nised and described as a separate affection in the 
fifteenth century, though in all probability it had 
existed at least for many centuries before that. When 
we first come upon a clear description of small-pox, 
we find that it was a disease almost confined to 
childhood — in fact, very much in the position of 
measles in the present day ; and this was due mainly 
to the fact that nearly all adults had had the disease, 
and the adult population practically represented for 
the most part the survivors from small-pox in child- 
hood. There were, indeed, some who appeared to 
be insusceptible to the disease, and these were thought 
to amount to about 5 per cent, of the population. 
Small-pox then attacked almost all of those who were 

97 G 






Vaccination 

exposed to its influence, unless they had already had 
an attack of the disease ; for, fortunately, the disease 
in large measure protects against itself. 

The frequency of small-pox in England in former 
centuries is not to be measured by the severity of 
any single epidemic, because in every epidemic the 
persons who could be attacked formed only a com- 
paratively small part of the population. For epi- 
demics came so often that at any one time the vast 
majority of the people had already had small-pox, 
and therefore it was only amongst those who had 
never had small-pox that it was possible for the disease 
to spread. Even with these great limitations of the 
activity of the disease in any one year, small-pox 
killed thousands in London alone when it became 
epidemic every few years. In isolated parts of the 
country, however, the case was somewhat different, 
for there children frequently escaped the disease, so 
that when later small-pox infection was brought into 
the district, the disease was no longer limited to the 
children, but attacked persons of all ages. The full 
virulence of the affection could be only seen in 
epidemics in countries where either it had never 
appeared before, or where for many years the disease 
had not been seen, for when it did come the popula- 
tion was entirely, or almost entirely, defenceless, and 
the results were indeed terrible. 

In Iceland, in 1707, small-pox had been absent for 
nearly forty years, yet when it did appear it slew 
eighteen thousand persons out of a total population 
of fifty thousand in the three years 1707, 1708, and 
1709. Greenland had its first epidemic of the disease 
in 1734, and two-thirds of the inhabitants perished. 
When small-pox first appeared in Mexico it is said 

98 



Vaccination 

to have swept over the land like fire over a prairie, 
and so great was the number of those who died of 
the disease that there was no possibility of burying 
them. Amongst the North-American Indians whole 
tribes are said to have disappeared. In England 
the disease appeared epidemically so frequently that 
though in each epidemic the numbers dying formed 
only a small part of the total population, yet the total 
mortality for a term of years from small-pox was 
very great. 

The ordinary mortality of the disease appears to 
have been about one in seven of those attacked, 
but in some of the epidemics the mortality was much 
higher, even reaching one in three. During the latter 
half of the seventeenth century in London the average 
number of deaths from small-pox was over one 
thousand a year, and as the population then was 
probably a little over half a million, and as it has 
been estimated that there was, on an average, one 
death in five cases of the disease, we shall probably 
not overestimate the number of cases if we say that 
there were five thousand cases of small-pox every 
year in London at that time. 

Dr. Jurin in 1723 calculated that more than seven 
per cent, of all deaths were from small-pox ; and this 
statement was based on the London Bills of Mortality. 
From various data referring to other parts of the 
country it appears that, speaking generally, the death- 
rate from small-pox was during the eighteenth century 
about three thousand per annum per million living. 

It was considered rather a misfortune not to have 
had small-pox while young, and "few people would 
choose even to hire a servant who had not had the 
small-pox." 

99 



Vaccination 

The first attempt made to mitigate the ravages of 
the disease was by the practice of inoculation. For 
centuries, in the East, it was known that a mild 
attack of the disease could be produced by taking 
some of the matter from a case of small-pox and 
inserting it in a minute incision of the skin. It is 
difficult to say where inoculation first started, but 
there seems to be some evidence in favour of the 
view that it originated in Circassia. The first mention 
of the matter is contained in a letter from Con- 
stantinople, written by Emanuel Timoni, and com- 
municated to the Royal Society by Dr. Woodward 
in 1714. It was also described in a book published 
by Kennedy in 1715, and he gives a full account 
of the methods employed. The practice prevailed 
amongst the Arabs, and we are told, at Mousul the 
appearance of small-pox was announced by a public 
crier, so that those who wished might have their 
children inoculated. Inoculation was a very ancient 
custom in India, and in China it had been practised 
about two hundred years. 

In 1720 Lady Mary Wortley Montagu, whose hus- 
band was Ambassador at Constantinople, learned of 
the method there, and introduced it into England, and 
she showed her belief in the value of the method 
by having her little boy inoculated in England in 
that year. 

Slowly the practice was adopted, but after a time 
it became more widely used, and, as I have mentioned 
in the chapter on Immunity, it often caused so little 
disturbance to the persons inoculated that they were 
not confined to bed, and therefore, as they mixed 
with their friends, they tended rather to spread the 
disease. The opinion has been expressed by some 

100 



Vaccination 

that inoculation increased the mortality from small- 
pox, but it is certain that a very definite increase 
in the death-rate from small-pox had occurred in 
this country before inoculation was introduced. 

The value of inoculation was definite for the in- 
dividual, but on the whole it was harmful to the 
community ; yet it continued until it was replaced 
by vaccination. 

For a long time, it is difficult to say how long, 
in several parts of the country, especially in the West 
of England, the belief had existed amongst those who 
had to do with cows, that a disease from which cows 
sometimes suffered, called cow-pox, when com- 
municated to the milkers afforded them protection 
from small-pox. It is certain, at all events, that 
attempts made to inoculate dairymaids often failed 
when they had suffered previously from an attack 
of cow-pox. Mr. Rolph, who practised at Thornbury 
in Gloucestershire, estimated that he had met with 
sixty cases in which he had failed to produce small- 
pox by inoculation, and all of these cases were per- 
sons who had been previously affected with cow-pox. 
The tradition was well known to inoculators, though 
some did not believe it. 

In 1771 it is said that a butcher living near Brid- 
port was intentionally inoculated with the cow-pox, 
because it had been suggested to him that it would 
be the means of preserving him from the small-pox. 
After he had recovered from the cow-pox he was 
twice inoculated with small-pox, but each time un- 
successfully. There is good evidence also that a 
farmer named Benjamin Jesty of Yetminster, in Dorset, 
had inoculated his wife and two children with cow- 
pox in 1774, in order to prevent their taking small-pox, 

101 



Vaccination 

but the particulars were not published until after 
Jenner's discovery. 

Edward Jenner was born in 1749 at Berkeley, in 
Gloucestershire, and when eight years old he was 
inoculated for small-pox. The preparation for the 
inoculation lasted six weeks, and during this time he 
was bled, kept on a low diet, and given a " diet drink 
to sweeten the blood." At the age of thirteen he was 
apprenticed to a surgeon at Sodbury, near Bristol, 
and there he remained for six years. While an 
apprentice an incident occurred which it is said first 
turned his attention to cow-pox. A young country- 
woman who was being treated, told him that she 
could not take small-pox as she had had cow-pox. 
At the age of twenty-one he went to London, and there 
he became a pupil of the celebrated surgeon John 
Hunter, with whom he lived for two years. He 
assisted Hunter in forming the valuable museum, 
which later became the foundation of the Museum 
of the Royal College of Surgeons of England. 

After studying in London he returned to Berkeley, 
where he commenced practice. Here, in addition to 
his professional work, he interested himself in many 
Natural History subjects, and he appears to have been 
the first to recognise that the young cuckoo itself 
turns out the other young birds from the nest in 
which it lives. The fact has been denied many times 
since, but a few years ago it was shown to be true. 
For some years Jenner interested himself in the 
natural history of cow-pox, and he believed that it 
spread to cows from a disease of the heel of the horse 
called the " grease." From observation he proceeded 
to experiment, and in 1796 he had vaccinated several 
cases with lymph taken from cases of cow-pox, and 

102 



Vaccination 

in each case a subsequent attempt to inoculate with 
small-pox failed. Jenner wrote a paper on the subject 
and sent it to the Royal Society, but it was not 
approved by the Council of that body, and therefore 
it was returned to him. 

His pamphlet was published in 1798, and it was 
called " An enquiry into the causes and effects of the 
variolae vaccinae, a disease discovered in some of the 
western counties of England, particularly Gloucester- 
shire, and known by the name of the cow-pox" ; and 
in it he explains his reasons for thinking that cow-pox 
can prevent small-pox. 

At first the new idea was not very readily received, 
but gradually the practice of vaccination spread. 
There were several who opposed it, and some cases 
occurred which seemed to throw doubt on its efficacy, 
but the successful cases were so numerous that the 
apparent failures were disregarded. The practice 
spread to the continent of Europe and to America, 
and it was received almost everywhere with enthusiasm, 
an enthusiasm which appears strange to us who see 
so little of small-pox. Practically within six years 
vaccination became known and employed throughout 
the world. Jenner spent the rest of his life in advo- 
cating his discovery, and in taking care that real 
vaccine lymph was employed. 

Jenner himself believed that he had discovered "an 
antidote capable of extirpating from the earth a disease 
which is every hour devouring its victims — a disease 
that has ever been considered the severest scourge of 
the human race." It was not long, however, before 
this view had to be modified. It had almost been 
forgotten that small-pox itself does not always prevent 
a subsequent attack of the disease, and even when 

103 



Vaccination 

inoculation was common, occasionally an attack of 
small-pox occurred in persons who had been pre- 
viously inoculated. 

Further, it was at one time thought that a single 
vaccination would confer complete immunity for the 
rest of life, but it has been found that after a time a 
tendency exists for the patient to lose this immunity, 
for it seems clear that the immunity does diminish 
after some years, and therefore there is need for re- 
vaccination. With vaccination and re-vaccination 
efficiently performed, practically complete immunity 
is afforded. 

In spite of vaccination small-pox still lingers in this 
country. To what is this to be attributed ? At the 
present time vaccination is theoretically compulsory, 
though in some towns, such as Leicester, those in 
authority neglect to carry out the provisions of the 
act authorising compulsory vaccination. Further, it 
is now legally possible for parents who declare that 
they have conscientious scruples against having their 
children vaccinated, to obtain permission for the non- 
performance of the vaccination. 

There is, then, slowly growing up amongst us a 
large body of unvaccinated persons, and these form a 
body of material on which the disease flourishes when 
it appears. Further, it must not be forgotten that the 
mode of performance of vaccination is not always 
satisfactory. There appears to be some connection 
between the number of vaccine pustules formed and 
the amount of protection afforded. When in the 
early sixties a great many vaccinated children were 
examined, it was found that only one in three could 
be considered well protected. It is not improbable 
that before many years an epidemic of small-pox will 

104 



Vaccination 

appear in this country which will demonstrate the 
unsatisfactory condition of the enforcement of the 
law of compulsory vaccination. 

The best example of a well-vaccinated country is 
Germany. In the entire German Empire the average 
mortality from small-pox in the ten years ending 
1899 was 1.07 per million, that is to say, about one- 
tenth of the English rate in the same years. Vaccina- 
tion in Germany is compulsory, and re-vaccination is 
compulsory when all children are at school age, and 
when recruits are enrolled they are again vaccinated. 

At the present time it is customary nearly every- 
where to employ calf vaccine, that is to say, lymph 
obtained from calves which have been vaccinated. 
Before the calves are vaccinated, they are tested for 
tuberculosis. This lymph, taken from the calves, is 
diluted with glycerine ; this serves not only to increase 
the number of cases which can be vaccinated with a 
certain quantity of vaccine, but also to kill many of 
the extraneous germs which may happen to be 
present. 

An important question has to be answered. Does 
harm ever follow vaccination ? It may confidently 
be said that if due care be taken in the source of the 
lymph, and if the operation is performed with due care 
on healthy children, no harm will ever follow. If, 
however, care be not taken, severe or even serious 
results may follow. 

Vaccination used to be performed from arm to arm, 
and, provided that the giver of the lymph is perfectly 
healthy, the practice is perfectly safe ; but it is often 
not possible to be certain that the child from whose 
arm the lymph is taken is in perfect health ; and in 
many of the cases where harm has followed vaccina- 

105 



Vaccination 

tion, it has been due to the fact that the source of the 
lymph has been tainted. It is obvious, further, that 
the child about to be vaccinated must be in good 
health, that its arm must be clean, and that the instru- 
ment with which the operation is performed must be 
aseptic. Even, however, when all these precautions 
have been taken, harm may follow because of the 
neglect of those whose duty it is to look after the 
child. The vaccinated area should always be pro- 
tected by a piece of clean linen. " Vaccination shields" 
are often employed, and they are saved from one case 
for use on subsequent cases, with the result that they 
are generally very septic and fully capable of spreading 
disease. It may be seen, therefore, that with due care 
the risk of danger resulting from the operation of 
vaccination is extremely small, but were the risk 
greater even than it is, it would be well worth while 
taking in order to obtain immunity from small-pox. 

I have said little hitherto as to the theory of vaccina- 
tion. Nearly all observers now agree that cow-pox 
is really small-pox of the cow, so modified by its 
passage through that animal as to have lost nearly 
the whole of its virulence ; but it appears that it is still 
capable of giving rise to the formation in the body of 
the person vaccinated of those antibodies which are 
formed naturally in a case of small-pox and which 
are capable of antagonising both the organism of 
small-pox and the toxins to which that organism gives 
rise. In the chapter on Immunity, other instances 
are quoted of weakening of the virus of a disease. 
The conditions of growth determine the virulence of 
a microbe, and the growth of the microbe of small- 
pox in the cow so weakens it as to make it, when 
re-inoculated into man, a mild disease. 

1 06 



CHAPTER XI 

DIAGNOSIS 

Diagnosis is the technical name for the recognition 
of a disease. Sometimes it is very easy, the disease 
being recognisable at a glance ; while at others it is 
extremely difficult, and all the assistance provided by 
the numerous aids to diagnosis which we possess may 
be required before a certain opinion can be formed. 

No small part of the greater success which attends 
modern treatment when compared with the treatment 
of former days is to be ascribed to the vast improve- 
ments made in the art of recognising a disease and of 
distinguishing one disease from another. 

A correct diagnosis is the first step in treatment ; 
nay, more, it is hardly an exaggeration to say that an 
exact diagnosis, a correct appreciation of the whole 
morbid condition present in the patient, is half the 
treatment. It is true, that even with an incorrect 
diagnosis a cure may be possible, but this is due, 
partly to the fact that the same treatment may be 
efficacious in several different diseases, and partly to 
the power which the body possesses in a high degree 
of curing itself ; the vis medicatrix natures, or the 
healing power of nature, is capable of doing much. 

There are not rarely occasions when the physician 
or the surgeon has to acknowledge that he is unable 
to say exactly from what malady the patient is suffer- 
ing ; this is not uncommon at an early stage of a dis- 

107 






Diagnosis 

ease, but usually, before long, new symptoms or signs 
appear on which the diagnosis can be based. A re- 
fusal to make a diagnosis, when the facts needed for 
it are unobtainable, is not to be taken as any proof of 
ignorance ; it may well be an evidence of knowledge, 
for a man less acquainted with the subject might 
have less hesitation in framing an opinion. 

We see, therefore, that though a good result may 
follow an incorrect opinion as to the nature of the 
disease, every effort should be made to find out 
exactly what affection is present. Even in a machine 
so simple as a watch, the recognition of what is 
wrong must precede any really intelligent attempt at 
putting it right. It is unnecessary to say more in 
support of the immense importance of a correct 
diagnosis. 

A diagnosis is based partly on the history of the 
patient, partly on his own account of his symptoms, 
and partly on the physician or surgeon's examination 
of the patient. The relative value of these three 
sources of information varies in different cases. 
Sometimes, as in the cases of infants', no account 
can be obtained of what the patient feels. On the 
whole the most important of these sources is the 
information obtained from the examination of the 
patient, and in this matter the progress of science 
has given to the medical profession several diagnostic 
aids of great value, and in this chapter I will describe 
some of the more important of them. 

Percussion 

One of the first great steps in the extension of 
our diagnostic powers was the introduction of per- 

108 



Diagnosis 



cussion. Before this time the physician's knowledge 
of the interior of the chest was based chiefly on the 
presence of various symptoms, such as cough, short- 
ness of breath, feverishness and wasting, but of direct 
knowledge there was almost none. In 1761 Auen- 
brugger of Vienna introduced into medicine the 
method of percussion. 

The value of percussion depends on the fact that 
a membrane when struck will vibrate freely and give 
out a sound if it is surrounded on both sides by air 
or other gas ; but it will not vibrate if on even one 
side a liquid or a solid substance is pressing against 
it. Thus a drum will give out a clear sound when 
struck, only if there is air on both sides of the drum- 
head ; if either side is in contact with a solid, only 
a dull sound will be heard, and the same result will 
follow if either side is in contact with a liquid. The 
explanation of these facts is that air must surround 
a membrane if it is to vibrate freely, and the larger 
the surface that can vibrate the deeper the note. 
When a solid or liquid touches one surface of the 
membrane, its freedom of movement is so greatly 
obstructed that it cannot vibrate freely, and as a result 
a dull note is produced. 

Although the use of percussion in diagnosing the 
condition of the chest was introduced by Auenbrugger 
in 1761, it was not until 1808 that, in consequence of 
Corvisart's advocacy, the method became widely used. 
Its great value is clear. The heart consists of so 
much solid material, and it lies so close to the surface 
of the chest, that the percussion sound over it is 
quite dull, but where the lung is close beneath the 
chest wall the sound obtained by percussion is clear 
and resonant, because the lung contains a very large 

109 






Diagnosis 



proportion of air. Therefore the percussion note over 
a healthy heart is dull, and over a healthy lung it 
is clear. When, however, as a result of inflammation, 
as in pneumonia, portions of the lung become much 
more solid than in health, the note obtained by per- 
cussion will be duller than normal. 

In this way, by means of percussion, it is possible 
to learn much as to the conditions existing within 
the chest, and percussion is almost equally useful in 
diagnosing the affections of the abdomen. The way 
in which percussion is performed has varied some- 
what from time to time. At first the chest was 
tapped with the finger, but the sound so elicited was 
not definite. Later a small block of ivory or ebony 
or some similar substance, called a " pleximeter," was 
placed on the part to be examined, and this was 
struck with a small hammer or with the finger. At 
present it is customary to place a finger of the left 
hand over the spot and to strike it with a finger of 
the right hand. With practice as clear a note can 
be obtained in this manner as is possible with the 
use of an instrument, and it is much more convenient 
for the physician not to have to carry about with him 
a special instrument. 

Another and perhaps even more valuable method 
of examining the organs of the chest is auscultation. 

Auscultation 

About the beginning of the nineteenth century it 
had become not unusual for many physicians of Paris 
to listen to the sounds of the heart by placing the 
ear to the chest, and in 1819 Laennec, who had 
employed this method of listening to the heart, 

no 



Diag 



nosis 



thought that the heart-sounds could be conveyed 
better to the ear if some solid medium were inter- 
posed. He experimented with a roll of paper, and he 
found that he could hear the sounds more distinctly, 
and therefore he devised the "stethoscope." This 
instrument consists essentially of a cylinder with a 
central perforation, and at each end is an enlarge- 
ment — at one end for the physician to apply to his 
ear, and at the other for application to the chest of 
the patient. 

By employing the stethoscope Laennec was able 
to hear, not only the sounds of the heart, but also the 
sounds which are given out by the lungs in health 
and disease, and he may be said to have founded the 
art of diagnosis by auscultation. 

Some additions have been made to the conclusions 
at which Laennec arrived in the auscultation of the 
heart and lungs, but these additions have been small, 
and to his investigations was due a very great advance 
in the diagnosis of the organs contained in the chest, 
so that at the present time the physician, by means of 
percussion, auscultation, and other similar methods, 
is able to arrive at very accurate conclusions as to the 
conditions existing within the chest. The stethoscope 
of Laennec was about a foot in length, and its porta- 
bility was somewhat increased by making it in two 
pieces which were screwed together for use. A little 
later Pierry made a smaller and lighter instrument, 
removing most of the wood between the two ends, 
which were left larger ; the end for the patient's chest 
being smaller than the end intended for the physician's 
ear. This pattern has endured to the present day, 
and it is preferred by many, but a more convenient 
pattern has, in a great measure, replaced it. This is 

in 



Diagnosis 

called the binaural stethoscope, for it is made to 
apply to both ears of the physician. The " chest - 
piece " for applying to the patient's chest is very 
much the same as the chest-piece of the wooden 
stethoscope, and from it come two tubes which are 
connected by means of rubber tubing to the earpieces. 
The advantages of this form of stethoscope are, that 
both ears are utilised in hearing and that it is more 
easily applied to all parts of the chest of the patient. 
Although Laennec, the inventor of the stethoscope, 
considered that it assisted the hearing, this opinion 
is not held by most physicians, for it is now gener- 
ally agreed that by placing the ear to the chest the 
physician can hear more clearly than by means of a 
stethoscope ; but the " direct method " of auscultation, 
as it is called, has many inconveniences, and the 
stethoscope is much more readily applicable. 

By means of auscultation disease of the heart can 
be recognised. The condition of the lung also and of 
the pleura which surrounds it can be ascertained with 
a high degree of accuracy. 

The Clinical Thermometer 

One of the most striking deviations from health 
occurring in many diseases is an elevation of tem- 
perature. From the earliest times the presence of 
fever was well known to those who had the care of 
the sick, but it was not possible to recognise with 
certainty slight elevations of temperature merely by 
feeling with the hand, or to detect small variations 
occurring during the course of a febrile attack. The 
thermometer was used long ago occasionally in 
medicine, but it was not till i860 that its use became 

112 



Diagnosis 



at all common. At first the clinical thermometer was 
large, but now it is very small and portable. 

The thermometer is placed under the arm or in the 
mouth under the tongue. In the mouth the tempera- 
ture is generally about half a degree higher than in 
the armpit. The normal temperature of the mouth 
is about 98.6 Fahrenheit, corresponding to 37 Centi- 
grade, and this point is usually marked on the 
thermometer by an arrow. 

At first it was necessary to wait some five minutes 
before the mercury in the thermometer had risen to 
its full height, but now, by making the glass thinner 
and the bore narrower, it has been possible to obtain 
thermometers which will give a true reading in a 
minute or even half a minute, though it is always 
well to leave the instrument in position for a little 
longer time than it is said to require. In the early 
thermometers it was necessary to observe the level 
to which the mercury had risen before removing the 
thermometer from its position in the mouth or under 
the arm, for the mercury would begin to fall even 
while the thermometer was being removed from its 
position. It was not very long, however, before an 
ingenious device was invented which served to retain 
the mercury at the height to which it had risen. The 
bore of the tube was greatly constricted at a point 
a short distance above the bulb. The great force 
exerted . by the expanding mercury is sufficient to 
force some of the mercury past the constriction into 
the tube above, but this portion of the mercury cannot 
return past the constriction as its weight is insufficient, 
and therefore the upper border remains at the level 
it had reached while in the mouth or armpit. 

In many modern clinical thermometers the front 

113 H 



Diagnosis 

of the instrument is curved, so that it acts as a lens 
and enables the fine column of mercury to be more 
easily seen. Still another improvement has been in- 
troduced. In most clinical thermometers the degrees 
are scratched on the outside of the glass. This 
arrangement has several disadvantages, of which the 
most important is that in the scratches might lodge 
bacteria, and these might not be removed when the 
thermometer is cleansed. In some recent instruments 
the degrees are marked on the interior of the glass, 
so that the surface is perfectly smooth, and it is there- 
fore much more easily kept clean. 

Although 98.6 is called the normal temperature, 
it must not be forgotten that even in perfect health 
the temperature may vary nearly a degree, the highest 
temperature being found at night and the lowest in 
the early morning. The judicious use of the thermo- 
meter is of great value in the recognition of disease, 
and if the temperature is found in any case to be 
normal, it is possible to exclude many morbid con- 
ditions. It is, however, possible to pay too much 
attention to the thermometer, and unfortunately many 
people are in the habit of taking frequently their own 
temperatures and the temperatures of their children, 
and if even a slight rise is present they are worried ; 
for they imagine that some disease is commencing. 
This is foolish, for it is a misuse of a useful instrument, 
and it causes much unnecessary anxiety. 

The Ophthalmoscope 

The treatment of all but the superficial diseases of 
the eye was unsatisfactory so long as surgeons were 
unable to see into the interior of the eye during life. 

114 



Diagnosis 

On attempting to look into an eye through the tran- 
sparent pupil it appears quite dark, and nothing can 
be seen because the head of the observer completely 
shuts off all light from the observed eye. Sometimes 
if an eye is looked at from a distance of five feet or 
so, it is possible to see through the pupil a red glare 
which is really the structure at the back of the eye. 
This is often seen in animals : in dogs the colour is 
usually green. It is only possible to observe the 
retina in this way when sufficient light can get into 
the eye, and the further the observer's head is away 
from the observed eye, the less it blocks out the light. 

The ophthalmoscope was invented by Helmholtz 
in 185 1. In its earliest form it consisted merely of a 
plate of glass placed obliquely between the observer 
and the observed eye. Rays of light from a lamp 
fall on to the glass, and by it are reflected into the 
observed eye ; the rays emerging from the eye pass 
(in part at least) through the glass and enter the 
observer's eye, who, in this way, can see the interior 
of the patient's eye. In a later and much more effec- 
tive form, a mirror with a central perforation replaces 
the glass plate, and a much better view is obtained. 

There are two methods of using the ophthalmo- 
scope ; in one, which is called the " direct method," 
the observer's eye is placed near to the observed, and 
the rays of light pass straight from one to the other. 
In the other method, which is called the "indirect," 
the observer is about two feet from the observed eye, 
and a convex lens is interposed between the mirror 
and the observed eye. In this way a real image is 
formed which is seen by the observer. In all modern 
ophthalmoscopes, lenses both concave and convex 
and of various strengths are placed behind the mirror, 

"5 



Diagnosis 



and these are used to correct any error of refraction 
on the part of either the physician or the patient. 
The ophthalmoscope, in addition to its very great 
value in diagnosis, is also used to estimate the power 
of the spectacles required in cases of defective vision 
due to errors of refraction ; and the results obtained 
by the ophthalmoscope can be employed to confirm 
or correct the results obtained by the patient's 
attempts to read type ; and further, the ophthalmo- 
scope can be employed to ascertain the errors of 
refraction in young children who are unable to read. 

The Laryngoscope 

The larynx is the upper part of the air passage, and 
contains the apparatus for producing the voice. The 
difficulty of ascertaining what changes occurred in 
the larynx during life had rendered it very difficult 
to know the conditions existing in it, and therefore 
treatment was often unsatisfactory. 

The laryngoscope is an instrument devised for 
examining the interior of the larynx. It was invented 
by Babington in 1829, and he described it under 
the name of " glottiscope." Similar attempts were 
made by Liston and Trousseau. Little was really 
done, however, till 1854, when Garcia the celebrated 
singer improved the method. He reflected the rays 
of the sun into the back of his mouth by means 
of a mirror which he held in his left hand ; then 
he introduced a dental mirror into his mouth, and 
thus he was able to see an image of his own larynx 
in the mirror. He was able to study the movements 
of the vocal cords, both when at rest and when 
sounding a note. 

116 



Diagnosis 

The laryngoscope consists essentially of two mirrors. 
One of these measures four inches or so in diameter, 
and is fixed to the surgeon's forehead. This mirror 
is concave, and has in its centre a perforation through 
which the surgeon can look. The other mirror is 
much smaller, about an inch or less in diameter, and 
it is fastened at an angle to a long handle. The 
laryngoscope is used in the following manner. The 
patient sits on a chair, and on one side of his head 
is a good light. The surgeon with the large mirror 
on his forehead is seated opposite the patient, and 
arranges the mirror so that the light is reflected by 
the forehead mirror into the patient's mouth. The 
patient puts out his tongue and holds it 3teady with 
a cloth, or sometimes the surgeon holds the tongue. 
The surgeon then takes the small mirror and warms 
it, so that the moisture from the patient's breath may 
not condense on it and so obscure the view. The 
small mirror is then passed with care into the back 
of the throat. The rays of light are reflected by the 
forehead mirror into the patient's mouth, where they 
meet the small mirror and are reflected into the 
larynx, which they illuminate. The returning rays 
are reflected by the throat mirror, and so find their 
way back to the surgeon, passing through the per- 
foration in the large mirror. The discomfort pro- 
duced by the mirror in the throat may be prevented 
by swabbing the part with a solution of a local 
anaesthetic, such as cocaine. 

In this manner with practice a very accurate view 
can be obtained of the interior of the larynx, and 
with the assistance of the laryngoscope applications 
can be made to the vocal cords or other structures, 
and small growths can be removed. 

117 



Diagnosis 



Within the last few years a new method has been 
invented of examining the larynx. It is called " direct 
laryngoscopy " ; for it is possible when the head 
is thrown far back to pass a straight instrument 
through the mouth directly into the larynx, or 
even farther still. In this way not only can the 
larynx be examined with great ease, but it is also 
possible to see the lower part of the air tube (the 
trachea, as it is called), and even the upper part of 
the bronchi. 

Through the cavity of the direct laryngoscope in- 
struments can be introduced into all the main air 
passages, and foreign bodies, such as pins, can be 
removed with a certainty and ease impossible before. 
The risk to the patient has been greatly reduced, and 
a process occupying a few minutes has, in suitable 
cases, been substituted for a long and difficult 
operation. 

Rontgen Rays 

One of the greatest helps to the surgeon in the 
diagnosis of injuries and disease of bones and joints 
has been afforded by the discovery of the Rontgen, 
or X-rays. 

There are several methods by which Rontgen Rays 
can be obtained, but the simplest is perhaps the 
following : — A primary electric current is taken from 
an electric battery, from accumulators or from the 
electric light mains, and the last of these is certainly 
the most convenient for ordinary purposes. This 
primary current is sent through the primary coil of 
an " induction coil," and it is " broken " many times 
a second by a special kind of interrupter. The effect 

118 



Diagnosis 

of this rapid interruption of the primary current is 
to induce in the " secondary " wire of the coil a 
current of very high voltage. Wires from the 
secondary poles are led to an X-ray tube. This tube 
consists of a glass globe, and at one end is a small 
metal disc called the negative pole or " cathode/' and 
at the other end is the positive pole, or, as it is often 
called, the "anticathode." In some tubes there are 
two anticathodes, but it is not certain that this is any 
improvement. The anticathode is made of platinum, 
and it is inclined at an angle of 45 to the axis of 
the tube. Nearly the whole of the air in the tube 
is pumped out before the tube is sealed, and then 
it is ready for use. When an electric current of 
very high voltage is passed through such a tube from 
which nearly all the air has been pumped, particles 
of air containing charges of negative electricity pass 
from the cathode towards the anticathode, which they 
strike, and reflected from this they are turned side- 
ways towards the glass, which glows with a green 
tint, and from the glass the Rontgen Rays pass off. 
These Rays are invisible to the unaided sight, and 
they possess the power of passing through many 
bodies which are opaque to ordinary light ; thus 
paper and wood offer very little resistance, while 
metals offer great resistance to the Rontgen Rays, 
and the heavier the metal the greater the resistance. 
If an X-ray tube is placed on one side of a limb 
and a photographic plate is placed on the opposite 
side, and a suitable current is passed through the 
tube, it will be found, on development of the photo- 
graphic plate, that the plate will have been affected 
unequally by the rays, according to the structures 
intervening between the lamp and the plate. The 

119 



Diagnosis 

skin and the muscles will have allowed nearly all 
the Rays to] pass through them, but the bones will 
have obstructed the greater part of the Rays, so 
that beneath the bones the photographic plate will 
have been but little affected. 

Before this important addition to our diagnostic 
aids, i the surgeon was generally able to recognise with 
accuracy most of the fractures and dislocations he 
met with ; but Rontgen Rays have greatly increased 
his diagnostic power. Even at present the surgeon 
still diagnoses the condition present by inspection and 
palpation ; but he has in the X-rays a means of 
testing, confirming, or correcting the opinions he has 
previously formed. In most cases his diagnosis is 
found to be right, but sometimes it happens that 
the Rays show, on the print or " skiagram " as it is 
called, that some other bone or joint injury is present 
in addition to what was at first thought. Thus as the 
surgeon's diagnosis is rendered more accurate, the 
results are better. 

In examining an injury by means of the X-rays we 
can either employ a fluorescent screen or we can 
take an X-ray photograph. The screen consists of 
a layer of cloth which has been coated with the 
cyanide of barium and platinum, and when this is 
placed in a current of X-rays with a part of the body 
between, those tissues which obstruct the Rays greatly 
will give a dark shadow on the screen, while opposite 
those which obstruct the Rays slightly the screen will 
be bright, because where the X-rays are not blocked 
they cause this chemical substance to become phos- 
phorescent. Sometimes the screen is enclosed in a box 
which shuts out all other lights, so that the screen can 
be examined in daylight, but the objects can be seen 

120 



Diagnosis 



more clearly in a room that is completely darkened. 
If necessary, a surgeon can operate while the tissues 
are exposed to the Rays, and in this way it is possible 
to see that the instruments are used to the best ad- 
vantage. When such a thing as a toothplate has 
become impacted in the gullet it may sometimes be 
removed with ease under the Rays, because the 
forceps which are used to extract it can also be seen 
as they approach it, and the surgeon can thus make 
sure that he is grasping it where it should be seized. 
Another way is to mark with ink the position of the 
object on the skin, while the screen is in use. 

To obtain a photograph or, as it is better called, a 
"skiagram " of a part by means of X-rays, the photo- 
graphic plate is placed so that the limb or the part to 
be photographed is between the plate and the X-ray 
tube ; and then the Rays are turned on for a longer 
or shorter time. The Rays are now much more pene- 
trating than at first, and the plates have been made 
more sensitive, so that the exposures to the Rays 
have become very much shorter. Indeed, by using 
extremely large currents of electricity, skiagrams have 
been taken in a fiftieth of a second. The photographic 
plate is developed in the ordinary way, and it will be 
a " negative " from which a u positive " can be printed. 
Even the condition of the heart and lung can be 
recognised by means of X-rays ; the change in ishape 
of the heart as it beats can also be seen, and, in fact, 
it has been possible to obtain cinematograph films of 
the heart. Very early disease of the lungs, such as 
tuberculosis, may also sometimes be recognised by 
means of a skiagram, before other methods of examina- 
tion give proof of the presence of disease. 

An aneurism is a dilatation of an artery, and a 

121 



Diagnosis 

common site of an aneurism is the aorta, or the large 
artery of the chest. In the diagnosis of an aneurism 
of the aorta, X-rays may prove of distinct value. 

To demonstrate the form of a hollow organ like the 
stomach, which has a thin wall, and therefore cannot 
give a distinct shadow, it is necessary to introduce 
some substance into it which can give an X-ray 
shadow. Preparations containing salts of bismuth 
or salts of iron can be used, and it is possible to see 
the movements of the stomach as it contracts and 
expands during digestion. 

It is clear from the short account I have given that 
even up to the present diagnosis has received re- 
markable assistance from the X-rays, and in the 
future it is not improbable that still further aid may 
be afforded by their use. 



122 



CHAPTER XII 

THE STORY OF THE DISCOVERY OF 

ANAESTHESIA 

A great obstacle to the performance of operations 
in the past was the fear of pain, for it often prevented 
a sufferer from consenting to an operation, even 
though he knew that he would in all probability be 
cured or at least benefited by it ; and therefore one 
of the most important inventions in connection with 
Surgery during the last century was the introduction 
of a method by which operations could be performed 
without causing pain to the patient. 

Anaesthesia in operations was no new idea. Homer 
refers to the power of nepenthe in relieving pain, 
and both Dioscorides and Pliny mention the use of 
mandragora for preventing pain in operations. 

Dioscorides says that a preparation made from the 
root of mandragora was given to those " about to be 
cut or burnt by the cautery, for as they are thrown 
into a deep sleep they do not feel the pain." Pliny's 
reference to it is expressed in very similar terms, and 
he even states that it is possible in some cases for the 
smell of the drug to produce sleep. 

Apuleius mentions that mandragora will cause sleep 
during which a limb can be amputated without the 
operation causing pain. The Arabian writers on 
medicine also describe the uses of this drug for re- 
lieving pain, and indeed in modern times a tincture 

123 



The Discovery of Anaesthesia 

prepared from mandragora has been found to cause 
sleep, during which a small operation can be performed 
without pain. 

In the Middle Ages various preparations for the 
prevention of pain during operations were in use ; 
some of these were secret preparations, and therefore 
it is impossible to say what they contained, but the 
composition of those which are described shows that 
the chief constituents were mandragora, opium, and 
henbane. Later the accounts of these anaesthetic 
drugs do not speak so enthusiastically of them ; 
perhaps some change in the method of preparation 
had occurred. 

Many text-books of Surgery, even up to the end of 
the eighteenth century, gave various prescriptions for 
draughts to be taken by patients before operation ; 
but on the whole they were very little employed, pro- 
bably because they were of little use. One of the last 
references to the employment of these preparations 
occurs in a treatise on Surgery written by Benjamin 
Bell of Edinburgh, the seventh edition of which was 
published in 1801 ; he mentions that narcotics of 
every kind might be employed for the purpose of 
lessening general sensibility, but that nothing answered 
with such certainty and effect as opium, yet as opiates 
when given in doses large enough for this purpose 
were apt to induce sickness and vomiting, he seldom 
ventured to give them before an operation. He also 
states that it had long been known that the sensibility 
of any part might not only be lessened but even 
altogether suspended by compressing the nerves that 
supply it, but here also he appears to doubt the 
practicability of the method. 

In 1776, Priestley discovered nitrous oxide gas, or 

124 



The Discovery of Anaesthesia 

laughing gas, as it is often called ; but it was not till 
1800 that Humphry Davy found that it possessed 
anaesthetic properties, and this discovery came about 
in a curious manner. Soon after oxygen had been 
first separated, attempts were made to employ it and 
hydrogen in the treatment of disease by inhalation, 
and in 1798 an institution was founded in Bristol by 
Dr. Beddoes for the purpose of employing the inhala- 
tion of gases in the treatment of disease, and Davy 
was appointed its superintendent. Here he had 
numerous opportunities of observing the effects of 
the inhalation of gases, and amongst others he experi- 
mented with nitrous oxide. On the 9th April 1799, ne 
tried it on himself, and he found that it possessed 
intoxicating properties, and that it relieved the pain 
of toothache. In 1800 he published the fact and he 
suggested that it might be used in operations, for he 
says, "As nitrous oxide . . . seems capable of de- 
stroying physical pain, it may probably be used with 
advantage in surgical operations in which no great 
effusion of blood takes place." Here we see the use 
of nitrous oxide by inhalation for the relief of pain 
and a suggestion for its employment in operations, 
but the suggestion fell to the ground, and nitrous oxide 
was not used again as an anaesthetic till 1844. 

Ether (or, as it used to be called, sulphuric ether, 
because it was made by the aid of sulphuric acid) 
was known to Raymond Lully, who wrote in the 
thirteenth century, and later its properties were studied 
by several observers, but it did not receive the name 
of "ether" until 1730. It was only employed as a 
stimulant medicine, until in 1795 Dr. Pearson of 
Birmingham used ether by inhalation for asthma and 
for consumption. A few years later Woolcombe of 

125 



The Discovery of Anaesthesia 

Plymouth employed the inhalation of ether for the 
relief of attacks of asthma, and then it was found that 
when the inhalation was continued sufficiently long 
the patient became unconscious. 

In 1818 Michael Faraday reported that the inhala- 
tion of the vapour of ether produced anaesthetic 
effects similar to those resulting from the inhalation 
of nitrous oxide. Within the next twenty years this 
anaesthetic property of ether was recognised by several 
American physicians. Both ether and nitrous oxide 
were also employed occasionally to afford amusement 
by causing exhilaration and partial intoxication, or 
even unconsciousness ; but the application of these 
properties to the relief or prevention of pain in opera- 
tions did not appear to suggest itself, or at least it 
never advanced beyond a suggestion. 

Before ether was accepted as an anaesthetic for 
surgical purposes, attempts were made to utilise 
mesmerism for the prevention of pain at operations. 
In the latter half of the eighteenth century Mesmer, 
after whom the method was named, had employed 
magnets in the treatment of disease, but after he had 
seen Gassner perform similar cures without using 
magnets, he discarded the magnets and evolved the 
idea that he possessed an occult force within him by 
which he could affect the nervous system of others. 
He met with much success in Paris in the treatment 
of various affections, and showed conclusively that it 
was possible to throw patients into a state of un- 
consciousness. He had many followers, and in this 
country the most deserving of mention was Dr. John 
Elliotson of University College Hospital, London. 
Later, James Braid of Manchester, commencing as a 
sceptic, investigated the subject, and under the in- 

126 



The Discovery of Anaesthesia 

fluence of mesmerism, induced by him, several opera- 
tions were performed, in some cases with complete 
success, but there were many failures. Even at the 
present day hypnotism, which is merely mesmerism 
under another name, is employed to a slight extent 
for the relief of pain, and to even a smaller extent for 
the prevention of pain during surgical operations. 
Sometimes, indeed, the anaesthesia seems to be perfect, 
but in only too many cases the diminution of sensi- 
bility is but slight, and in some there is no anaesthesia 
at all. The uncertainty of the method must pre- 
vent its use to any great extent now that we have 
such trustworthy anaesthetics as ether and chloro- 
form. 

Some investigations by R. H. Collier are worthy of 
mention as links in the chain of the utilisation of 
ether as an anaesthetic. He himself had experienced 
the power of inhaled ether vapour to cause un- 
consciousness when he had, as a student, attended 
lectures in London given by Dr. Turner at University 
College. Later he lectured in the United States on 
the value of the inhalation of the vapour of alcohol 
in which poppy heads and coriander had been steeped, 
in causing unconsciousness and freedom from pain ; 
and in 1842 he extracted a tooth from a patient who 
was under the influence of the alcoholic vapour, and 
the patient felt no pain. 

The next step forward was taken when, in December 
1844, Dr. G. Q. Colton, at a lecture at Hartford, 
Connecticut, demonstrated the action of nitrous oxide 
gas in causing exhilaration and unconsciousness. 
While one of the audience, named Cooley, was partly 
unconscious under the influence of gas, he fell against 
a bench and damaged the skin of his arm so severely 

127 



The Discovery of Anaesthesia 

that it bled, but he felt no pain ; in fact he was not 
aware of the wound until he saw the blood. 

Among the audience was a dentist named Horace 
Wells, and he was much impressed by the fact that 
Cooley had not felt his injury. As Wells had a carious 
tooth which needed extraction, he arranged with 
Dr. Riggs to extract the tooth, and he asked Dr. 
Colton to administer the gas to him. 

Dr. Riggs has given a graphic account of the opera- 
tion : " A few minutes after I went in, and after 
conversation, Dr. Wells took a seat in the operating 
chair. I examined the tooth to be extracted with a 
glass, as I usually do. Wells took a bag of gas from 
Dr. Colton, and sat with it in his lap, and I stood 
by his side ; he then breathed the gas until he was 
much affected by it ; his head dropped back ; I put 
my hand to his chin, he opened his mouth, and I 
extracted the tooth. His mouth still remained open 
some time. I held the tooth up with the instrument 
that the others might see it. . . . Dr. Wells soon 
recovered from the influence of the gas so as to know 
what he was about, and said, ' A new era in tooth- 
pulling.' He said it did not hurt him at all." 

Wells introduced the use of nitrous oxide into his 
dental practice and daily extracted teeth without caus- 
ing pain. He was much impressed with the value of 
his discovery and wished to employ it for surgical 
operations. With this intention he went to Boston, 
Massachusetts, but he could not find any surgeon will- 
ing to try the experiment. He was, however, allowed 
to administer gas to a patient who was to have a tooth 
extracted at the Massachusetts General Hospital. 
The anaesthesia was not a complete success, because, 
according to Wells, the bag of gas was removed too 

128 



The Discovery of Anaesthesia 

soon from the patient's mouth. Whatever the cause, 
the use of nitrous oxide for anaesthesia was discredited, 
and Wells was much depressed by the failure. 

Ether now comes on the scene. In 1842 Dr. C. W. 
Long, of Jefferson, Georgia, U.S.A., removed a small 
tumour from the neck of a patient who had been 
rendered insensible by the inhalation of ether. But 
as this and subsequent operations in which ether was 
used by Dr. Long were not published till 1849, some 
doubt has been thrown on his claim to be considered 
the introducer of ether as an anaesthetic. 

In September 1846 Dr. W. T. G. Morton of Boston, 
Massachusetts, who had been a pupil and later a 
partner of Wells, and had assisted Wells at the un- 
successful attempt to anaesthetise a patient at the 
Massachusetts General Hospital, wished to employ 
nitrous oxide gas for use in dentistry, but he was 
unable to obtain a supply, and it was suggested to him 
by C. P. Jackson that ether would have the same 
effect. Shortly after he had a suitable opportunity, 
and he administered ether to the patient and extracted 
the tooth without causing any pain. Morton wished 
to keep the discovery to himself, and patented it both 
in the United States and in Great Britain under the 
name of " Letheon," and a little later, on 16th October 
1846, Morton administered " Letheon" to a patient at 
the Massachusetts General Hospital while Dr. J. C. 
Warren removed a tumour from the neck. The 
anaesthesia was perfectly successful, for no pain was 
felt by the patient, and great interest was taken in the 
matter by many doctors who were present ; yet there 
was a little hesitation on the part of the surgeons to 
employ the substance, for Morton would not disclose 
its composition. It was, however, soon recognised 

129 1 



The Discovery of Anaesthesia 

that the anaesthetic agent was ether, for the odour 
could not be disguised, and then its use spread far 
and wide. It was not long before the news came to 
London, and on the 19th December of the same year, 
1846, Mr. Robinson, a dentist in London, removed 
the tooth of a patient anaesthetised with ether ; and 
two days later Robert Liston, at University College 
Hospital, amputated a thigh while the patient was in- 
haling ether. The cutting part of the operation lasted 
only thirty-two seconds, for Liston did not expect 
much from the ether, and therefore he operated as 
rapidly as if no anaesthetic had been given. 

From this time forward ether became widely used 
for the production of anaesthesia during operations, 
though there were a few who did not approve of 
the introduction of the employment of anaesthetics 
during an operation, but their opposition did not 
endure long. 5 

It is clear that to several is due the introduction of 
anaesthetics. While isolated employment had been 
made previously both of nitrous oxide and ether, yet 
the greater part of the credit must be given to Morton 
though he acted on the suggestion of Jackson. 
Morton petitioned the Government of the United 
States for a grant to him for the discovery of anaes- 
thesia for surgical operations, but his claims were 
contested by the friends of Long, Wells, and Jackson, 
and nothing was done. 

The well-known writer Oliver Wendell Holmes 
suggested the word " Anaesthesia." He wrote to 
Morton in November 1846 : i( Everybody wants to 
have a hand in the great discovery. All I will do is 
to give you a hint or two as to names, or the name 
to be applied to the state produced and to the agent. 

130 



The Discovery of Anaesthesia 

The state should, I think, be called Anaesthesia. . . . 
The adjective will be anaesthetic." 

The use of anaesthesia steadily extended, and the 
next important step was taken by Dr. James Simpson 
of Edinburgh. He early adopted the use of ether, 
but he was not fully satisfied with it, and he wished 
to discover some substance which would possess the 
advantages of ether without the disadvantages. It 
was not long before one or two deaths from ether 
had been reported. Simpson proceeded to test 
various liquids which he thought likely to prove 
useful as anaesthetics, and many subtances were 
suggested to him by others. In this work of test- 
ing he had the assistance of Dr. George Keith and 
Dr. Matthews Duncan, and it was their custom in 
the evening to inhale first one substance and then 
another, and thus to test their relative merits. In this 
way they had tested very many liquids, but nearly 
a year had elapsed before they tried chloroform. 
This substance had been suggested to him by Mr. 
Waldie, a chemist of Liverpool, who had sent him 
a small quantity. Chloroform had been discovered 
in 183 1 by three separate investigators about the 
same time, but it had been put to little use, though 
it was occasionally prescribed in medicines. 

On the 4th of November 1847 Dr. Simpson and 
his two friends started testing various liquids by 
pouring a small portion into a tumbler and inhaling 
the vapour, and after a time they tried chloroform, 
and as they began they described the odour as 
pleasant. It was not long before the three experi- 
menters became unconscious, and when they re- 
covered they found themselves prostrate on the, 
floor. Fortunately their recovery did not take long 

131 



The Discovery of Anaesthesia 

and as Simpson came back to consciousness he said 
to himself, "This is far stronger and better than 
ether." 

When they compared notes they all felt sure that 
a new and useful anaesthetic had been found. They 
made some more trials of it the same evening, and 
they were so satisfied with the results that they did 
not part till a late hour. 

A week later Simpson read a paper on the subject 
before the Medico-Chirurgical Society of Edinburgh, 
and shortly after this he arranged to administer chloro- 
form to a patient for an operation. However, he 
was unable to be present, and after a little waiting 
the operation commenced without any anaesthetic. 
At the first touch of the knife the patient died. It 
must be regarded as fortunate that Simpson was not 
present to give the chloroform, for if he had been 
there and the patient had died, the death would 
certainly have been ascribed to the chloroform. 
However, a week or so later chloroform was used 
with perfect success in three cases. 

In the British Isles ether was soon replaced as an 
anaesthetic by chloroform, but a change in this matter 
took place about 1868, and since that time there has 
been a partial return to the earlier anaesthetic. At 
the present time in England ether is extensively 
employed, though in Scotland chloroform still is the 
more widely used. In the United States of America 
ether is still preferred, especially in the Northern 
States. 

It is very difficult to administer ether in tropical 
climates, as in India, because ether evaporates at the 
comparatively low temperature of 96 F., therefore 
in most hot climates such as India ether is hardly 

132 



The Discovery of Anaesthesia 

ever employed, chloroform being used as the regu- 
lar anaesthetic ; the boiling-point of chloroform is 
140 F. 

Although nitrous oxide was the first anaesthetic to 
be employed, its use was soon discontinued, but in 
1863 it was reintroduced by American dentists as the 
most convenient anaesthetic for such short operations 
as the removal of a tooth. It is an excellent anaes- 
thetic, for it is capable of producing complete in- 
sensibility ; it is very safe in administration, rapid in 
its action, and patients recover quickly from it ; more- 
over, seldom does it give rise to any unpleasant 
after-effects. But the shortness of the duration of 
the anaesthesia which it produces limits its use to 
brief operations, such as removal of a tooth, the 
opening of an abscess, or the loosening of stiff joints. 
Within recent years, however, it has been possible to 
give the gas mixed with oxygen, and it then becomes 
suitable even for prolonged operations ; but used thus 
it is very expensive. Although other general anaes- 
thetics have been introduced from time to time, and 
various mixtures of anaesthetics have also been em- 
ployed, they are but little used at the present day, and 
the field of general anaesthesia is practically mono- 
polised by ether, chloroform, and nitrous oxide. 

As to the risk of anaesthesia, it may be said that 
while putting a patient into such an unnatural con- 
dition as complete anaesthesia and complete uncon- 
sciousness can never be wholly free from danger, 
yet in skilled hands the risk is small ; and it is well 
worth while to incur that r\sk in order to escape the 
severe pain of an operation. 

Another method of preventing a patient suffering 
pain during an operation is local anaesthesia, and of 

133 



The Discovery of Anaesthesia 

this there are two kinds. In the first form the part 
is frozen, for if a part of the body be frozen it be- 
comes completely anaesthetic. J. Arnott introduced 
this method in 1848, and he employed a mixture of 
ice and snow. This is effective, but it is not always 
available. A much more convenient method was de- 
vised in 1866 by Sir Benjamin Ward Richardson, who 
invented an apparatus by which a fine spray of ether, 
highly rectified, was thrown upon the part. The ether 
evaporates rapidly, abstracting so much heat from 
the tissues as to freeze them, and the skin soon be- 
comes white and hard. This method is still widely 
employed, but ethyl chloride is usually employed in 
place of ether, as it freezes the tissues more quickly. 
In the other method of local anaesthesia the nerves 
of the part are paralysed by the use of a suitable 
drug. Cocaine was introduced in 1884, and it was 
at first much used, and indeed is still often employed, 
but many substitutes, such as Eucaine, possess ad- 
vantages over the original substance, and therefore 
at present they are more widely used. A solution of 
one of these substances, of suitable strength, is in- 
jected underneath the skin, and in two or three 
minutes the part will have lost all sensation. These 
drugs are especially valuable in many operations on 
the eye and the mucous membrane of the mouth, 
throat, and nose, for they produce their effect even 
if they are merely placed on the surface, as they do 
not need to be injected. 

Within the last few years a third method of anaes- 
thesia has been employed called ''spinal anaesthesia." 
In this method a solution of cocaine, or more com- 
monly of one of its substitutes, is injected into the 
back so that it is close to the spinal cord. In this 

134 



The Discovery of Anaesthesia 

way the nerves of the lower half of the body have 
their sensation paralysed at their roots, so that, 
although the patient is fully conscious, he knows, by 
his sensations, nothing of the operation which is 
proceeding. It is clear that the method is not ap- 
plicable to operations on the head and neck, a.nd it 
has not as yet been widely employed in this country, 
but in France many surgeons seem to prefer it. 



135 



CHAPTER XIII 

ANTISEPTIC SURGERY 

In order to appreciate fully the enormous progress 
which has been made in surgery since the intro- 
duction by Lord Lister of the antiseptic method, it 
is essential for the reader to know something as to 
the results which were obtained previously. We 
know little of surgery before the fifth century B.C., 
but we find a very full account of its position at that 
age in the works of Hippocrates and his immediate 
followers, and from those writings we are able to see 
that during the many centuries which have elapsed 
surgery has made great and steady advances. One 
of the more serious obstacles to the progress of 
surgery had been the danger of loss of blood, but 
ultimately the use of the ligature for tying blood- 
vessels had become fully established in the latter 
half of the eighteenth century, and when the danger 
of haemorrhage was removed progress was at once 
visible. Another great obstacle to the extensive em- 
ployment of operations had been the fear of the 
pain necessarily incurred by the patient ; and it 
must not be forgotten that a great deal of the shock 
following an operation was occasioned by the pain, 
and this also had much harmful effect. These hin- 
drances to operation which depended on the un- 
avoidable infliction of pain were removed by the 

136 



Antiseptic Surgery 



introduction of anaesthetics, as I have described else- 
where, in Chapter XII. 

There remains yet a third difficulty which had to 
be overcome before surgery could enter into its full 
heritage. In the days before the introduction of 
antiseptic surgery, no surgeon could feel sure of his 
results ; however much care he may have taken in 
the planning and performance of the operation itself, 
however completely he may have prevented the loss 
of blood, he could not foretell with any approach to 
certainty whether the patient would recover from 
the operation or die as the result of its perform- 
ance. After an operation the patient might go on 
well for a day or two, but then, even in the most 
favourable case, the wound which had been produced 
began to secrete a large amount of matter or pus, 
as it is technically termed. Then even in favourable 
circumstances it would heal up very slowly, generally 
taking several weeks in the process, and for the 
greater part of this time fever and pain were present. 
This was a favourable result, or so it was considered 
then ; but unfortunately even this measure of success 
was not always attained. Only too often feverish 
attacks would come on a few hours after the opera- 
tion ; the fever would increase from day to day, and 
in a few days' time death would result from blood- 
poisoning. Sometimes inflammation would attack 
the skin surrounding the wound and erysipelas would 
appear, and not unlikely lead to a fatal issue. I have 
mentioned only two of the severe complications which 
might result, but really there were many ways in 
which death or a prolonged illness might follow the 
performance of an operation. 

Inflammation might appear round the wound, and 

137 



Antiseptic Surgery- 



gangrene might follow it, so that what was at first 
merely a small incision might become within a few 
days an extensive sore ; and if these results were likely 
to follow incisions made for the purpose of removing 
a growth or with some such object, similar results 
were even more likely to follow accidental wounds. 
A mere puncture with a sharp instrument, a stab 
with a knife, might be followed by the most severe 
consequences, even by death itself, though no im- 
portant structure had been wounded. Occasionally, 
indeed, wounds healed up at once " by first intention," 
as it is technically called ; but this was a result that 
did not often occur, and it was not encouraged, because 
the surface might heal and yet pus might form in 
the deeper parts of the wound, and this would need 
another operation for its removal. The most curious 
point about the results was that the surgeon could 
not say beforehand which case would heal by first 
intention and which would be followed by great in- 
flammation, by sloughing, or by death. Sometimes 
abscesses would form in other parts of the body, 
and to this the name of pyaemia was given, for it 
was thought that somehow the pus from the wound 
had made its way into the blood ; and then severe 
rigors or shivering fits would assail the patient, or 
profuse sweats might weaken him still further. 

It was recognised by surgeons in those days that 
a large proportion of the cases must suppurate, that 
is to say, must form pus, in ordinary circumstances, 
but occasionally epidemics of sepsis arose, especially 
in hospitals, and case after case would suffer from 
one or other of the septic diseases. Sometimes every 
case in the ward on which an operation had been 
performed would develop erysipelas ; sometimes case 

138 



Antiseptic Surgery 



after case would be attacked with pyaemia, and yet 
the surgeon was unable to say why these diseases 
appeared, or why they were absent. Sometimes it 
seemed as if the season of the year might be re- 
sponsible, and many were inclined to attribute to 
the spring a specially harmful influence ; sometimes, 
however, epidemics would show no predilection for 
any particular season. Every surgeon had some 
theory to account for the occurrence of these dis- 
eases, and some method to prevent their appearance, 
but for the most part their efforts appeared to be 
in vain. 

At last it was recognised that erysipelas and its 
allies did not appear in all circumstances. They 
appeared much more frequently in hospitals than in 
private practice, and they were certainly much more 
common among patients dwelling in towns than among 
those treated in the country. Even in the wards of 
the same hospital great differences occurred in the 
relative frequency with which cases of septic disease 
appeared in the different wards. After a time it was 
recognised that the overcrowding of a ward for 
more than a very short time was fairly certain to 
be accompanied by the appearance of one of these 
diseases, and especially by that spreading form of 
ulceration which was called hospital gangrene. In 
wars, when large numbers of the wounded were 
gathered together under one roof in buildings ill- 
adapted for the care of patients, hospital gangrene 
almost always appeared, though it was hardly seen at 
all amongst the wounded who were treated in the 
open air. The frequency of these diseases may be 
gathered from a few figures. From some statistics 
collected by Sir John Erichsen relating to 631 cases of 

139 



Antiseptic Surgery 



amputation before antiseptic surgery was introduced, 
it appears that no less than 86 died from pyaemia 
alone, and in all 239 deaths occurred. It must not 
be forgotten, however, that " shock" was responsible 
for ten per cent, of these deaths ; but when we put 
aside these, the remaining cases, more than two 
hundred in number, died from septic causes, that is 
to say, causes which with our present knowledge we 
may reasonably look upon as preventable. Of the 
cases infected by some septic disease the deaths varied 
between eighty and ninety per cent. Although the 
surgeons of those days could not assign to any known 
cause the septic complications of their operations, yet 
some among them, by special attention to detail, were 
able to obtain results superior to those of many of 
their fellows. Separation from other patients, and 
country air, were definitely advised, and cleanliness 
in everything connected with the operation certainly 
improved the results. Yet still, it was thought that 
suppuration, that is, the formation of pus, was a 
natural concomitant of a healthy healing wound. 

I have mentioned that sometimes it happened that 
the patients in some wards of a hospital were much 
more liable to be affected with septic diseases than 
the patients in other wards, and this fact, combined 
with the observation mentioned above, that septic 
diseases were much more common in hospitals than 
in private houses, led to the suggestion that hospitals 
should be merely temporary structures, and that after 
existing for a few years they should be pulled down 
and rebuilt. If surgery had thus arrived at the posi- 
tion that, in spite of the great surgical skill and manual 
dexterity of operators, the results were so uncertain 
that much hesitation was felt in operating on any case 

140 



Antiseptic Surgery 



but those where operation was essential, it was evident 
that some unknown factor was at work. 

In this condition was surgery when Lister devised 
the antiseptic method. 

Joseph Lister was born in 1827. His father was a 
man of some eminence in science, and he was especi- 
ally worthy of remembrance in connection with the 
perfecting of the compound microscope. Lister 
entered as a student of medicine at University Col- 
lege, London. In the epidemics of hospital gangrene 
which he saw at University College Hospital he had 
an opportunity of observing its mode of spread, and 
he was satisfied that it was not constitutional in origin, 
but due to some local cause. 

After working as house surgeon to the celebrated 
surgeon Syme of Edinburgh, Lister was appointed 
surgeon to the Royal Infirmary at Glasgow. About 
this time Pasteur was showing that all forms of fer- 
mentation were due to the presence in the fer- 
menting liquid of minute bodies, and that if care were 
taken to exclude these micro-organisms from the 
fermentable liquid no fermentation occurred. It was 
an act of genius to perceive the analogy which exists 
between the changes which occur in the fermenting 
liquid and suppuration in an open wound. Lister, 
seeing this analogy, was led to believe that if living 
germs could be excluded from the wound no sup- 
puration would occur. He perceived that these germs 
might come from the air, from the skin of the patient, 
from the surgeon's hands, and from the instruments 
employed ; but he was inclined to look upon the 
germs in the air as of special importance. We know 
now that he overrated the importance of the germs 
in the air ; nevertheless, the extra precautions he took 

141 



Antiseptic Surgery 



to exclude the germs from this source were only un- 
necessary and did but little positive harm. The form 
of wound that Lister chose for his first attempt to 
carry out in practice the theory he had formed was 
a compound fracture. To appreciate fully what he 
did, it is essential to understand what a compound 
fracture is. When a bone is broken but no injury 
is done to the skin, or rather there has been no 
wound of the skin communicating with the fracture, 
the condition present is called a simple fracture. In 
a simple fracture, if the fragments of the bone are 
placed in position and kept so, they will unite in a 
few weeks without any difficulty. There will be no 
fever, no real inflammation around the broken bone, 
and in fact, except for the discomfort of having a limb 
in splints and for being unable to take exercise, the 
patient is very little the worse for his broken bone. 

When, however, at the time of the breaking of the 
bone the skin in the neighbourhood of the fracture is 
torn or cut or pierced by one of the fragments, the 
condition is called a " compound fracture." Formerly 
a compound fracture was very much more serious 
than a simple fracture. Instead of healing swiftly 
and certainly as a simple fracture would, a compound 
fracture was always accompanied by a great amount 
of inflammation. The skin around the wound leading 
down to the fracture quickly became reddened, hot, 
and painful, and from the wound pus soon began to 
pour out. At the same time the patient was seized 
with fever. His temperature would run up many 
degrees ; severe shivering fits would attack him ; he 
was bathed from time to time with profuse sweats, 
alternating with acute febrile attacks. Various forms 
of blood-poisoning frequently occurred. Abscesses 

142 



Antiseptic Surgery 



might develop in different parts of the body ; erysipelas 
might invade the neighbourhood of the wound ; and 
weakened by these various assaults, worn-out by the 
high fever and the profuse sweating, in only too many 
cases the patient with a compound fracture died. 

Even if the patient eventually triumphed over these 
septic complications, it was often only by the sacrifice 
of a limb that he was able to overcome the attacks. 

This striking difference between the two forms of 
fracture forced itself on the attention of the surgeon 
at a very early date, and, so far as could be seen, the 
only difference between the two injuries was that in 
the case of a compound fracture the air had access to 
the broken bone, while in the other no air could get 
to the fracture. We now know that it was not the 
access of air which was responsible for the harmful 
results met with in compound fracture, but that they 
were due to the fact that through the wound of the 
skin and other soft parts the germs from outside made 
their way down to the site of the fracture. It is true 
that some of these germs are introduced by the air. 
Sometimes the fragments of bone may protrude and 
become contaminated, but a still greater risk arises 
from the ringers and instruments of the surgeon which 
are used to examine and replace the broken pieces of 
bone. 

It is therefore clear that the results of compound 
fractures were extremely bad, and very much worse 
than the results of simple fractures. Lister thought 
that it would be well to commence his attempts to 
prevent the entrance of germs into the wound by 
dealing with a compound fracture, for he felt that the 
results could not be made worse' even if the attempt 
failed, but if it should succeed the results would be 

143 



Antiseptic Surgery 

enormously better. In looking for a suitable anti- 
septic, Lister thought of carbolic acid, for he was 
acquainted with its very great efficiency in deodoris- 
ing sewage, and it was evidently a very powerful 
antiseptic. In the first case the undiluted acid was 
applied to wash out the interior of the wound as soon 
as the patient was seen, and then it was painted daily 
over the surface until the skin wound healed. Success 
followed the attempt, and it was not long before Lister 
was able to announce that, treated by his antiseptic 
methods, a compound fracture would heal in as simple 
and kindly a fashion as any simple fracture. At first 
he used the carbolic acid in an undiluted form, but 
he soon found that it caused an unnecessary amount 
of pain and damage to the tissues, and he discovered 
as the result of experiment that equally beneficial 
results were obtainable by weaker solutions. Al- 
though he applied the carbolic acid to the interior 
of the wound on the first occasion, he did not do so 
when the wound was dressed, for he held that the 
first application had been sufficient to destroy any 
germs that were present, and that subsequent applica- 
tions would serve only to irritate the tissues. 

Lister made many experiments to discover the best 
method of application of the acid and the best 
method of excluding germs from the wound ; he was 
not satisfied till he had found a method on which 
he could rely. The same antiseptic procedure was 
applied to operation wounds with the same happy 
results. The skin of the patient was carefully cleansed 
and wiped over with a solution of carbolic acid, and 
the hands of the surgeon were treated in a similar way, 
while the instruments to be employed in the operation 
were allowed to stand for about half-an-hour in a 

144 



Antiseptic Surgery 

solution of the acid. Lister attributed great import- 
ance to the air as a vehicle of germs, for he thought 
that germs, thousands of which are floating about 
suspended in the air, fell into the wound during the 
operation. It is true that this occurs, but we now 
know that he over-estimated the danger from these air- 
borne germs. Most of the bacteria infecting a wound 
come from the skin of the patient, the hands of the 
surgeon, or the instruments employed. To deal with 
the aerial germs Lister invented a carbolic spray, which 
was an apparatus for sending out by means of steam 
a fine spray of carbolic acid, which covered the whole 
area of operation. We now know that the spray was 
unnecessary and that occasionally it did some harm, 
and the absence of necessity for the use of the spray 
was first pointed out by Lister himself, and it has long 
been abandoned. 

This is a brief description of the introduction of 
the antiseptic method, and it is of interest to note 
how it was received. With regard to Lister's results 
there could be no real dispute. His wards in the 
Glasgow Infirmary were probably the least hygienic 
in the whole building, but the results which he was 
able to obtain after the employment of the antiseptic 
method far surpassed those attainable even in the 
purest country air. The publication of his method 
met with a very mixed reception. A few surgeons — 
for at first his imitators formed but a small minority 
— adopted his method and used his precautions, and 
according to the faithfulness with which they followed 
his instructions they attained results which could be 
compared with those of Lister himself. 

One reason why the process of adoption of the 
antiseptic method was not very rapid in this country 

145 K 



Antiseptic Surgery- 



was that many surgeons appeared to imagine that the 
employment of carbolic acid was the essential point 
in Lister's treatment. He had devised a principle 
of treatment, and they thought that he had introduced 
a drug. It is easy so to employ carbolic acid as 
to do but little good, and, in fact, its reckless use 
may easily lead to harm. Progress, however, was 
made, and gradually almost all surgeons adopted the 
antiseptic method. In other countries the introduc- 
tion of Listerism varied greatly, but it must be ac- 
knowledged that in Germany the new method was 
more rapidly appreciated than in Great Britain itself ; 
France, also, was not slow to adopt it. It is interest- 
ing to note that when Lucas-Championniere wished 
to employ the antiseptic method in Paris he was 
compelled to provide the dressings at his own ex- 
pense, for the hospital authorities would not consent 
to defray the cost ; and when he wished, at the out- 
break of the war with Germany, to take some carbolic 
acid with him to the seat of war, his chief would not 
consent. 

Statistics showed clearly the very great and rapid 
improvement effected in the practice of those who 
conscientiously and thoroughly practised the anti- 
septic treatment. The results were astonishing. With 
no change in any other particular, with the same 
class of patient, in the same wards and with the 
same operators, and for the same diseases and in- 
juries, the death-rate underwent a great diminution. 
The change produced did not consist only in the 
lessening of the death-rate, though that was the point 
of most importance, but in those who recovered the 
duration of the recovery was much reduced. Instead 
of a man taking many weeks or months to recover 

146 



Antiseptic Surgery- 
after a severe operation, he would be well within a 
fortnight ; and even the reduction in the amount of 
pain felt by the patient must not be left out of ac- 
count, for when a wound heals by first intention 
much less pain is felt, and it requires much less 
frequent dressing. 

When a limb was crushed, as by a cart-wheel, with 
extensive injury to the bone and soft parts, it was 
far wiser in the pre-antiseptic days to amputate the 
limb early, rather than to attempt to save the limb 
and to fail, for that would probably mean the death 
of the patient. It was soon found by those who 
followed the antiseptic teaching of Lister that it was 
possible to obtain rapid healing in many of these 
cases of severe injury, so that it was justifiable for 
the surgeon to attempt to save a damaged limb which 
without antiseptic precautions he would have felt 
compelled to amputate at once. 

When the surgeon found that he could almost 
guarantee the healing of a wound by first intention, 
he felt at liberty to operate more frequently and more 
freely than he had dared to do in earlier days. So it 
came to pass that the extent and frequency of opera- 
tions increased. Many conditions in which formerly 
the effect of the interference of the surgeon might have 
been even more disastrous than the results following 
merely medicinal treatment were now submitted to 
operation with incalculable benefit to the patient. 
Modern surgery may indeed be said to date from 
Lister's discovery. 

We have seen that many of the methods and pre- 
cautions adopted by Lister in his early operations 
were discarded as he gained experience with the 

147 



Antiseptic Surgery 



practice of his method. The carbolic spray was 
found to be unnecessary. At first strong solutions 
of carbolic acid were employed with it, and many 
surgeons used weaker and weaker solutions until the 
spray contained little more than water and yet the 
results were in no wise less satisfactory, until when 
the spray was done away with entirely the results 
were equally good. 

The elaborate dressings of gauze and mackintosh 
advocated at first were found equally to be unnecessary, 
and a simpler dressing was employed. It was then 
recognised more fully, that in an operation on a part 
where no wound had previously existed and no abscess 
was present, it was needless to introduce carbolic 
acid or any other antiseptic into the wound to destroy 
the germs, for there were no germs there to be de- 
stroyed. At first carbolic acid was used to sterilise 
the instruments, but later it was recognised that 
boiling was a more rapid and perhaps even more 
efficacious method. The dressings to cover in the 
wound at first contained carbolic acid ; then Lister 
introduced sal alembroth gauze, which contained 
perchloride of mercury or corrosive sublimate ; and 
later still he employed cyanide gauze containing a 
double cyanide of mercury and zinc, which was less 
irritating than either of the preceding dressings. 
Many surgeons, however, came to believe that it 
was unnecessary to have any antiseptic in the dress- 
ing, for in the study of bacteriology it has long been 
recognised that germs cannot pass through a layer 
of cotton-wool one inch thick, and therefore germs 
could not pass through a dressing consisting of many 
layers of gauze and wool. Therefore a dressing was 
introduced consisting merely of plain gauze and 

148 



Antiseptic Surgery 



cotton-wool, and it was found that this dressing was 
quite capable of preventing the entrance of germs 
from the air ; but it was essential that the gauze 
and wool should themselves be completely free from 
germs, or " aseptic " as it is termed. These dressings 
now are rendered aseptic either by steaming or by 
baking. So that, in the most recent form of surgery, 
chemical antiseptics are largely excluded from use, 
none being introduced into the wound, the instru- 
ments being sterilised by heat, and the dressings also. 
It is now recognised that so long as the surgeon 
takes care not to introduce any germs into the wound, 
if no sepsis has been previously present, the tissues 
themselves will be capable of dealing with the few 
that may accidentally make their way into it. There- 
fore modern surgery is often spoken of as "Aseptic 
Surgery," yet even at the present day it is not possible 
to sterilise by heat the skin of the patient or the hands 
of the surgeon and his assistants. It is still necessary 
to employ chemical antiseptics to render the skin of 
the patient as free from germs as possible. In the 
case of the hands of the surgeon and his assistants it 
has been found extremely difficult, and in the opinion 
of some impossible, to destroy absolutely every germ 
on them, though, with thorough washing and pro- 
longed soaking in an antiseptic solution, an approach 
to perfect asepticity can be attained. An attempt has 
been made to evade this difficulty in the case of the 
hands by wearing rubber gloves which have been 
rendered sterile by boiling, and it is probable that 
this is a useful detail in many operations, though, 
as the rubber gloves may be torn or pierced by a 
needle during the course of an operation, just as much 
care should be taken to sterilise the hands before 

149 



Antiseptic Surgery 



donning the gloves as if no gloves were to be used. 
It is customary to term the most modern surgery 
u Aseptic Surgery," as I have mentioned, but it must 
not be imagined that aseptic surgery is at all antagon- 
istic to or opposed to antiseptic surgery ; it is merely 
the latest modification of the application of the anti- 
septic principle enunciated by Lister himself, that 
every effort must be made to exclude germs from 
wounds. On the whole, it may be said that the 
practice of most surgeons of the present day consists 
in a judicious application of the principles of anti- 
septic surgery, modifying the practice according to 
the requirements of the individual case, but recog- 
nising that the tissues of the body are for the most 
part free from germs, and that a wound made in 
tissues free from germs cannot be improved by the 
introduction of an antiseptic, which, if it has any 
action at all, must only cause unnecessary irritation. 
When a wound is already septic the case is altered, 
and here the judicious application of antiseptic sub- 
stances may exert a very favourable effect. 

The success of antiseptic surgery is attested by 
forty years of an ever- widening application. It is pro- 
bable that the lives saved by Lister's teaching must 
now be numbered by millions, and, in addition, 
operations have caused far less pain to those who 
have had to submit to them. Of all the many bless- 
ings which the medicine of modern times has con- 
ferred on the human race, none can compare with 
antiseptic surgery. 



150 



CHAPTER XIV 

THE ARREST OF HEMORRHAGE 

To stop bleeding, whether it be the result of an acci- 
dental injury or whether it come from a wound in- 
tentionally inflicted in an operation, has always been 
one of the more important functions of the surgeon. 
Even amongst savage races we find various methods 
adopted for the purpose of arresting haemorrhage, 
and some of them correspond very closely to those 
which were employed by surgeons in civilised coun- 
tries during past ages. It is needless to elaborate 
the necessity for rapidly putting a stop to bleeding. 
Every drop of blood contains many millions of red 
corpuscles, and it is of the greatest importance that 
they should not be lost to any great extent. There 
are some five million red corpuscles in every cubic 
millimetre ; and in a cubic inch of blood there are 
about eighty thousand millions of red corpuscles. 
They are essential because they carry oxygen from 
the lungs to all parts of the body, and this oxygen 
is absolutely necessary to the life and action of the 
tissues. Therefore, if they are greatly diminished in 
number, life cannot continue, and when many of 
them have been lost weeks or months may elapse 
before the loss is regained. 

In health many, many thousands of red corpuscles 
are manufactured every second ; but after great 
haemorrhage they do not seem to be made so rapidly 

151 



The Arrest of Haemorrhage 

as in health. The whole body contains about one- 
thirteenth of its total weight of blood, so that if we 
may say an average human being weighs 130 pounds, 
there will be about ten pounds of blood in the body, 
that is to say, about a gallon. It has been calculated 
that about a third of this can be lost and yet life will 
be maintained, but there is risk that even a smaller 
loss than this may have a serious if not fatal result. 

I have mentioned these facts in order to show how 
extremely important it is that haemorrhage should be 
arrested early. 

Haemorrhage has a tendency to arrest itself. When 
blood is shed it soon begins to clot, as every one 
knows ; and this marvellous clotting power of blood 
is due partly to the liquid part of the blood but 
partly also to the white corpuscles, which appear to 
sacrifice themselves by becoming disintegrated and 
so assisting in the clotting of the blood. If it were 
not for this coagulating power of the blood, even 
small cuts would continue to bleed without ceasing 
and would lead to death. There were three main 
methods employed in early stages of civilisation for 
the arrest of haemorrhage, and we find two of them 
still in popular use even at the present day. Of these 
two methods the first acts by assisting the coagulation 
of the blood. If blood be received into a vessel it 
will clot much more rapidly if the vessel contains any 
finely divided particles or an irregular surface. This 
fact has been utilised to assist in stopping haemorrhage, 
for we find that certain leaves have been employed, 
such as those of the " wound-wort," which are covered 
with many fine downy hairs, and the Matico leaf, 
which has a very rough surface. The blood becomes 
entangled, as it were, in these irregularities, and clots 

152 



The Arrest of Haemorrhage 

rapidly. This is the principle on which cobwebs are 
employed to stop bleeding, for the many fibres of the 
cobweb favour coagulation. It may be as well to 
mention that cobwebs are very unsuited for a dressing 
to be applied to a bleeding spot, as they are always 
very septic, and many deaths have occurred from their 
application to wounds, especially from infection with 
the tetanus bacillus. Cotton-wool acts similarly in 
assisting in the coagulation of the blood, and if aseptic 
it may be useful for small wounds. Another method 
by which the arrest of haemorrhage is effected is by 
the application of certain substances called styptics, 
which possess the power of contracting the blood- 
vessels, so that the openings become slightly smaller 
and therefore more easily closed by blood-clot. This 
method, though effective when the vessels wounded 
are not large, is rarely used by surgeons at the present 
day, for in most cases the styptic damages the tissues 
greatly and tends to prevent them healing by first 
intention. There is, however, one substance recently 
introduced into surgery which has a wonderful power 
of contracting the smaller vessels, and thus of arrest- 
ing haemorrhage, without damaging the tissues at all. 
Above each kidney is a small gland called, from its 
position, the sjjrjrarenal body_. We know but little of 
its function, but it is certain that an extract made 
from it can contract the small blood-vessels and thus 
can assist in stopping bleeding. Therefore at the 
present day surgeons sometimes employ a solution of 
the extract of the suprarenal gland to assist in stop- 
ping the oozing from the smaller blood-vessels, but 
it is of very little value in arresting the haemorrhage 
from a blood-vessel of even moderate size. 

The third agent which seems to have been em- 

153 



The Arrest of Haemorrhage 

ployed in early times for the purpose of stopping 
haemorrhage was the cautery. A piece of iron heated 
to a red heat was applied to the bleeding spots, or 
drawn across the surface of the wound. This method 
was certainly efficacious, and occasionally it is em- 
ployed even at the present day. It has, however, one 
great disadvantage ; for the burnt surface cannot heal 
by first intention, it is very liable to become septic, 
and when the burned sloughs are thrown off it is 
not at all rare for the bleeding to recommence. 
Sometimes the heat was employed in another way, 
as after a gunshot wound the raw surface was treated 
with hot oil, which certainly had the effect of putting 
a stop to any haemorrhage present, but it caused severe 
pain for many hours afterwards. The tale has often 
been told how Ambroise Pare, who was surgeon to 
Francis I. of France, found himself after one engage- 
ment without any oil to apply to the wounds, so that 
it was with much misgiving that he treated his patients 
with a simple dressing. To his surprise, those patients 
treated with a simple dressing passed much less pain- 
ful nights than those who had been submitted to 
the then orthodox treatment of boiling oil. The 
improvement in the general condition of the patient 
was so great that he determined to employ this 
method in future, and this was made easier from the 
fact that he re-introduced the use of the ligature for 
tying blood-vessels. The ligature could not be called 
a new method in Ambroise Pare's time, for it had 
been known to and employed by Galen fourteen 
centuries earlier, and it had been used for many years 
after Galen's day ; but it had practically been forgotten 
until Pare" brought it forward again and employed 
it widely, and showed that it was a very satisfactory 

154 



The Arrest of Haemorrhage 

method of preventing haemorrhage from the larger 
arteries during and after amputation. 

The ligature remains to-day the most simple and 
the most trustworthy of all our methods of stopping 
bleeding. Until the introduction by Lister of the 
antiseptic method of treating wounds, the silk or 
thread with which a blood-vessel was tied was left 
long, so that when the ligature was loosened by sup- 
puration it might be pulled out ; this occurred a week 
or so after the ligature had been applied, and about 
the time when the ligature came away it was not 
unusual for haemorrhage to come on again ; this 
was called secondary haemorrhage, and when it 
appeared it gave much trouble, for it was often very 
difficult to stop. Since the introduction of antiseptic 
surgery it has been possible for the surgeon in almost 
all cases to ensure the absence of germs from the 
wounds, and therefore, as suppuration does not occur, 
secondary haemorrhage is now almost unknown, and 
the surgeon may with confidence cut the ends of the 
ligature short and leave it in the wound. 

There has been much improvement in the material 
of which ligatures are composed. Formerly thread 
was employed, and before use it was well waxed. 
These ligatures were not aseptic, and it is hardly 
necessary to say that no precautions were taken to 
keep them aseptic ; in fact, at one time it was cus- 
tomary for the house-surgeon to put the ligatures in 
his button-hole, so that they could be conveniently 
withdrawn one by one as they were required. It 
is not surprising, therefore, that in those days the 
ligatures always set up suppuration, which continued 
until they were removed. At present silk and catgut 
are mainly used, and there is some difference of 

155 



The Arrest of Haemorrhage 

opinion as to which is the better of the two. Silk 
is more easily sterilised, for it can be boiled ; but it 
is absorbed very slowly, and therefore sometimes it 
acts as a foreign body and gives rise to inflammation, 
even though it is quite free from germs. Catgut has 
the great merit of being absorbable, and by varying 
the method of preparation the rate of absorption can 
be adjusted within certain limits, so that the surgeon 
can, at his choice, employ one piece of catgut which 
will be absorbed in ten days, or another piece of 
catgut which will resist absorption for six weeks. 

There is no doubt that this absorbability of catgut 
renders it desirable for many purposes, for if it is 
absorbed it can never cause irritation later on. Cat- 
gut, however, has the very great disadvantage that 
it is naturally a septic substance, and that it requires 
very great care to render it free from germs, for it 
will not stand boiling in water. These difficulties 
can, however, be overcome, and catgut that has been 
suitably prepared is a very good material for ligatures 
and for sutures. 

The most valuable method for the temporary arrest 
of haemorrhage after an injury, or for the prevention 
of loss of blood during an operation, is undoubtedly 
the tourniquet. This in its original form consisted 
of a band passing round the bleeding limb, and into 
the loop a short stick was inserted by which the 
loop could be tightened when the stick was twisted 
round, and it was called a tourniquet because of this 
twisting. 

Many forms of the instrument have been invented 
from time to time, and each has some merit. The 
most generally convenient form at present is one 
consisting of a piece of rubber-tubing with very thick 

156 



The Arrest of Haemorrhage 

walls. This is made to encircle the limb at least 
twice, and then it is fastened so that it cannot come 
undone. This form was introduced by Esmarch, the 
celebrated German surgeon. It is especially useful 
for accidents, for it is light and so it can be easily 
carried about, and it can be readily and quickly ad- 
justed even by those who are unacquainted with 
anatomy and therefore do not know where the large 
blood-vessels of the limb are to be found. 

With some other forms of tourniquet it is necessary 
to adjust a pad exactly over the main artery of the 
limb, and therefore they are more difficult to apply. 
Esmarch's tourniquet is very widely used, and is of 
very great value. 

In all haemorrhages the faintness which the patient 
feels from the loss of blood tends to make him fall 
down so ;that he lies in a horizontal position, and 
this is really the best position for a patient losing 
blood, because then the heart beats less forcibly and 
much less frequently, so that the blood has a greater 
chance of clotting at the mouths of the vessels, and 
the haemorrhage may cease spontaneously. Well- 
meaning bystanders, in their excess of zeal, appear 
to have a natural inclination to raise the patient into 
a sitting position on the ground or on a chair, and 
unfortunately these well-meaning efforts are generally 
productive of harm. It is far better to let the patient 
lie at full length on the ground. If the haemorrhage 
is coming from an arm or a leg, that limb may be 
raised, and this may suffice to stop the haemorrhage. 

I have mentioned that a cautery at a red heat has 
been employed to stop haemorrhage ; but a much 
lower temperature is also sometimes useful. If water 
at a temperature of about 120 Fahrenheit be applied 

157 



The Arrest of Haemorrhage 

to a bleeding surface, the vessels will contract, and 
all the bleeding will stop that comes from small vessels. 
This temperature can be guessed fairly well, for the 
water is just as hot as the hand will bear. Water 
cooler than this, say at ioo° Fahrenheit, will increase 
the bleeding. Cold will also control bleeding, but 
not so thoroughly as very hot water, for as soon 
as the cold is removed the vessels relax and the 
bleeding is likely to recommence. The cold may 
be conveniently applied by the use of an ice-bag, 
which is a rubber bag containing pieces of ice. 



158 



CHAPTER XV 

SHOCK 

There are three great causes of death after opera- 
tion ; these are sepsis, haemorrhage, and shock. In 
Chapter XIII. I have described the wonderful results 
of the introduction of antiseptic surgery ; I have 
shown the marvellous effect the employment of the 
methods introduced by Lister had on the mortality 
of wounds, both accidental and occurring after opera- 
tions. In Chapter XIV. I have described the methods 
employed to diminish the loss of blood during opera- 
tion ; I have shown that with modern appliances, 
some of them indeed very old though recently re- 
introduced, surgeons have been able almost com- 
pletely to put an end to mortality from haemorrhage 
occurring in the course of an operation. Only one 
great cause of death remains, and that is shock. 
Though much has been done of recent years to 
combat it, even now it cannot be said that we have en- 
tirely succeeded in abolishing shock during operations. 
Shock is a frequent cause of death after accidents 
as well as after operations. When a man receives 
an extensive yet superficial burn and dies within a 
few hours his death is almost certainly the result of 
shock. \Vhen a limb is crushed by a train, and death 
comes within the first few hours, it will rarely be due 
to haemorrhage ; it will never be due to sepsis, but 
nearly always it will be the result of shock. Shock is 

*59 



Shock 

a convenient name for the deadening effect on the 
nervous system caused by a severe injury. The whole 
central nervous system becomes, as it were, powerless. 
The feeble pulse and the pallid face show the weak- 
ness of the action of the heart, and the shallow breath- 
ing indicates at what a low ebb are the nervous 
functions. Complete unconsciousness may be present, 
or in response to a spoken word the eyelids may be 
raised and a few half-audible words may be uttered, 
but the eyelids quickly droop again and the patient re- 
lapses into his former condition. In a severe case, 
unless the reaction comes, and comes soon, death 
must ensue. 

It will be clear that the amount of shock will depend 
in the first place on the severity of the injury in- 
flicted. A crushed finger, or an operation on the 
hand, will cause very much less shock than the lacera- 
tion of a whole limb or an amputation at the shoulder. 
If two limbs require to be amputated at the same 
time the chance of recovery will be materially dimi- 
nished. In many cases the effect of haemorrhage will 
add greatly to the amount of shock, and sometimes 
the word " collapse" is used, when shock is accom- 
panied by severe haemorrhage. It is obvious that 
the greater the injury to a part, the greater the 
shock that will follow, and even if no haemorrhage 
be present intense shock may result. 

The mental condition of the sufferer at the time 
of the infliction of the injury has a material influence 
on the severity of the shock produced. An injury 
inflicted on a man already depressed mentally and 
in a low state of health will have far greater effect 
in causing shock than will the same amount of 
physical disturbance in a man healthy both in mind 

160 



Shock 

and body. The difference may be sufficient to turn 
the scale. Every one knows how excitement will 
enable a man to bear easily an injury which other- 
wise might have produced no small amount of shock. 
In the excitement of battle very severe injuries have 
been endured ; even a limb has been torn away, and 
yet no pain may have been felt, and no shock may 
have been inflicted. It must not be forgotten that 
the depressing effect of pain has no small share in 
the production of shock. This is shown in many 
ways, but especially is it clear from the fact that 
anaesthetics have been found not only to do away 
with the feeling of pain but also to go far to lessen 
the amount of shock produced. The most striking 
effect of shock is its action on the circulation. The 
pulse becomes extremely feeble, often barely per- 
ceptible, and this effect is brought about in two ways ; 
first, the heart is weakened by the violent impres- 
sion on the nervous system due to the injury, and 
secondly, many of the large veins of the abdomen 
are, as it were, paralysed, so that they dilate and 
contain so much blood that the remaining vessels 
are only partly filled ; as a result the blood pressure 
undergoes an enormous fall, so that the whole body, 
especially the nervous system, is insufficiently supplied 
with blood. Naturally the result will be far worse, 
if at the same time a large amount of blood has been 
lost by haemorrhage. This is not the place to de- 
scribe in detail the treatment of the condition, but 
two methods which have been adopted to deal with 
the great fall of blood pressure in shock may be 
mentioned. The first method is to introduce into 
the blood-vessels of the patient some blood from 
another person. At one time, indeed, attempts were 

161 L 



Shock 

made to utilise the blood of sheep or other animals, 
but such attempts were foredoomed to failure because 
the blood of man and of sheep cannot be mixed 
without the destruction of the red corpuscles of one 
or both. Transfusion of the blood of one person 
into the veins of the other is very seldom done 
nowadays, though it is not very uncommon in novels. 
The objections to it are, first, that it is not at all 
easy to get a suitable person to supply the blood ; 
secondly, if any real good is to be done the quantity 
to be transfused must measure at least half a pint ; 
thirdly, the blood may clot during its passage from 
one person to the other or after it has entered the 
veins of the recipient ; and lastly, the giver of the 
blood often has a long and tedious convalescence 
before he regains completely his former health. 
Direct transfusion, as this method is called, has been 
almost completely replaced by the transfusion of 
saline solution. A solution of common salt is made 
of a strength which has been found not to damage 
the corpuscles of the blood. This is prepared with 
water free from germs and it is heated to a tempera- 
ture several degrees above the temperature of the 
body, so that it may not produce any chilling effect. 
It is then slowly injected into a vein of the patient. 
If it is injected sufficiently slowly large quantities 
may be introduced, and as it is obtainable almost 
everywhere it has come to be a valuable method of 
treating shock readily available in emergencies. Even 
so large an amount as several pints has been intro- 
duced with benefit. In suitable cases, if due pre- 
cautions are taken the results are often marvellous, 
so that some persons even moribund have been 
brought back to life. The same saline solution may 

162 



Shock 

also be injected into the tissue under the skin ; this 
method is simpler than the intravenous method, and 
it is safer, but its action is not so rapid. 

With modern precautions it is possible to eliminate 
shock from operations to a very great extent, though 
much still remains to be done. 



163 



CHAPTER XVI 

WHAT MODERN SURGERY CAN DO 

In previous chapters I have explained that the three 
great difficulties in the past in the more important 
operations of surgery were sepsis, haemorrhage, and 
shock. Sepsis is now, thanks to the work of Lord 
Lister, no longer a necessary accompaniment of 
every surgical operation ; for with care and attention 
to detail it has become almost possible to guarantee 
the absence of germs from the field of an operation. 
Further, many methods have combined to render the 
loss of blood at operations extremely small, and 
lastly, we can to a very great extent control the 
amount of shock which follows an operation. Thus 
the main dangers of an operation have been greatly 
reduced in severity. Armed with the weapons which 
the progress of surgery has put into his hands the 
surgeon of to-day can undertake and bring to a suc- 
cessful conclusion operations which not very long 
ago would have been considered beyond the bounds 
of possibility. An amputation even of a whole limb 
can now be carried out with a very small risk of a 
fatal ending, and in fact death hardly ever follows 
such an operation, unless it has been performed soon 
after a severe accident, which has rendered the opera- 
tion necessary. In such cases the death is to be 
attributed mainly to the original injury, though 
necessarily the shock of the operation, however 

164 



What Modern Surgery Can Do 

rapidly, however skilfully performed, must have con- 
tributed, in some degree, to the fatal ending. 

In a matter such as this a surgeon will often find it 
difficult to decide as to the best time for an operation. 
If performed at once, the shock of the operation is 
superadded to the shock of the injury, while if the 
operation is postponed, the loss of blood by oozing 
may be serious and the chance of sepsis definitely in- 
creased. The amount of shock resulting from an 
injury varies greatly in different cases even when the 
amount of damage done is much the same. It may 
be mentioned that the shock in cases of railway in- 
juries is usually exceedingly great, for the violence far 
surpasses any other form of injury to which we are 
liable. Injuries to the head and to the heart have 
very much shock, and as a rule the greater the extent 
of tissue injured, the greater the amount of shock. 
There are, however, many exceptions to this general 
rule, and many cases occur in which very severe 
injuries have been inflicted, and yet very little shock 
has resulted. In moments of great excitement 
severe injuries may give rise to no pain and to no 
shock. In the excitement of a cavalry charge an arm 
has been carried away by a cannon ball and yet no 
pain has been felt and no shock has followed. This 
absence of shock, or at least of apparent shock, is also 
very noticeable amongst the insane. 



Cancer 

In few parts of surgery has more progress been 
made than in the treatment of cancer. We have no 
certain knowledge of the causes of this disease, though 
it is becoming more and more clear that heredity has 

165 



What Modern Surgery Can Do 

very little to do with the occurrence of cancer ; this is 
directly opposed to the opinion formerly held, when 
it was thought that cancer occurred in certain families. 
Until recently operations on cancer gave not very 
favourable results, for in nearly all cases the disease 
returned sooner or later. At the present time surgeons 
have fully recognised two things in connection with 
cancer. The first is that the operation has to be more 
thorough than was thought sufficient before, and the 
second is that the operation must be done at an early 
stage of the disease. At one time it was thought that 
cancer was a general disease of the body, though it 
manifested itself only at one or two spots ; but now 
it is known with certainty that cancer is at first 
entirely a local disease and that if this local disease be 
removed completely it will not return, but that if it is 
left too long it may affect many parts of the body. 
The conclusion to be drawn from this fact is that any 
operation for its removal must be thorough, and it 
must also be performed early while the disease is still 
confined to its original site. In cancer, therefore, 
early and thorough operation can give a very great 
probability of complete and permanent recovery from 
the disease. 

The vital importance of early operation in any such 
condition must be borne in mind, and time should 
not be wasted in trying other methods of getting rid 
of the disease, for they can only lead to a postpone- 
ment of the best treatment. 

At present we do not know of any medicine capable 
of removing a cancer from the body, but it is not 
improbable that in time such a medicine may be dis- 
covered. It is not that we do not have substances 
put forward as cures for cancer. Probably every year 

166 



What Modern Surgery Can Do 

one u cancer cure" at least is brought forward. Its 
value is attested by many cures, but experience shows 
its lack of value. Unfortunately hitherto all u cancer 
cures " have failed. New remedies suggested for the 
cure of cancer always receive trial, and it is only after 
trial that they are condemned. Violet leaves, thyroid 
extract, and many other remedies have been brought 
forward within recent years, but all alike have come 
to nothing. 

Some very superficial forms of cancer, such as 
" rodent ulcer," have been successfully treated by 
means of X-rays and by radium, but these superficial 
forms must not be confused with the deeper and 
more severe forms of the disease, and for these latter 
forms there is at present no satisfactory treatment 
but operation. When, however, a case of malignant 
disease has become so extensive that the surgeon does 
not feel justified in operating, then it is clearly justifi- 
able to employ almost any form of treatment which 
has been recommended, provided that it does not give 
rise to unnecessary pain. 

The Surgery of the Brain 

Until a few years ago operations on the skull were 
confined to trephining or " trepanning/' that is, cutting 
a hole through the skull ; this indeed was a very 
ancient operation, for we find that it was performed 
even in the neolithic age, and it is certain that some 
of the patients survived then, for the wound in the 
bone shows signs of healing. Until the coming of the 
antiseptic method, however, the operation of trephining 
involved much risk to life ; now, in itself, it may be 
said to be practically free from danger. 

167 



What Modern Surgery Can Do 

The advances of our knowledge of the physiology 
of the brain have resulted in enabling the physician 
to determine often within very narrow limits the 
situation of tumours in the brain ; and in cases where 
these localising signs have been clear, surgeons have 
found it possible to remove the tumours with success. 
It is clear that such an operation must be attended 
with great risks, but the seriousness of a tumour in 
such a situation justifies great risks being undertaken. 

In a few cases by means of the X-rays it has been 
possible to determine the situation within the skull of 
a bullet, and its removal has been carried out with 
striking success. That such an operation should have 
been possible is entirely owing to the introduction of 
the X-rays. Abscess of the brain occasionally follows 
long-standing suppuration of the ear, and yet, on 
many occasions it has been possible for the abscess 
to be found, to be opened and be drained, and the 
operation to be followed by complete recovery. As 
prevention is always more important than cure, it 
may here be mentioned that most of these abscesses 
would have been prevented by a timely operation 
on the ear. 



The Surgery of the Heart 

Probably the most striking of all the advances 
of modern surgery is to be found in the surgery 
of the heart. The time has not long gone by when 
it was thought that any wound of the heart must 
inevitably prove immediately fatal, but cases are 
on record in which a wound of the heart has oc- 
curred and yet death has not followed for many 
minutes or even for several hours. One case is re- 

168 



What Modern Surgery Can Do 

corded in which a man received a bullet in the 
neighbourhood of the heart and he recovered, and 
when he died some years later the bullet was found 
embedded in the substance of the heart. It was not, 
however, until 1896 that the first attempt was made 
to operate for the treatment of heart wounds. 

A typical history reads as follows : — A man aged 23 
was stabbed in the chest by a dagger and as a result 
he lost much blood and became almost unconscious. 
The surgeon, by means of an incision, laid bare the 
heart, exposing the wound in it, and then he carefully 
inserted some stitches through the walls of the heart 
so as to close the opening. The superficial wound 
was then closed and the patient made a good recovery. 
Every year has added to the number of cases in which 
operations such as this have been performed, till up to 
the present some two hundred cases of operations 
on the heart for stabs and bullet wounds have been 
published and of these nearly fifty per cent, have re- 
covered. It is obvious that in cases such as these the 
mortality must be very heavy. It is certain that if 
nothing had been done almost every single case 
would have died, but, thanks to modern surgery, it 
has been possible to snatch from death nearly half 
the cases. 

At first surgeons felt a very natural hesitation in 
placing stitches in the heart substance, for they feared 
that they might interfere with the working of the 
heart, but experience has shown that the heart is 
much more tolerant than was thought. 

Whether it will ever be possible to do more in the 
way of operation on the heart than the stitching up 
of wounds of its walls, time alone can show ; with 
our present knowledge and our present experience it 

169 



What Modern Surgery Can Do 

seems almost impossible that more can be done than 
has been done ; but it would be unwise to declare 
that, in this matter, the future can have no surprises 
for us. 

The Surgery of the Abdomen 

The advantages of the antiseptic method in surgery 
have been nowhere more clearly seen than in surgery 
of the stomach, the bowel, and the other abdominal 
organs. Before Lister's epoch-making discovery the 
surgeon had the greatest hesitation in opening the 
abdomen, and in this attitude he was fully justified, 
for the results of the few operations undertaken were 
not such as to encourage him to venture to do much 
more. To-day the situation has completely changed, 
for when due precautions are taken the surgeon has 
no hesitation in operating on the organs of the 
abdominal cavity, and the results are eminently 
satisfactory. 

Probably the operation on the abdomen which is 
most frequently performed is for the removal of the 
M appendix." The vermiform appendix is a small 
hollow projection from the commencement of the 
large bowel, and it is called vermiform because it 
resembles, somewhat, an earthworm ; so far as we 
know it has no function, and we look upon it as only 
a relic of a part of the digestive apparatus which has 
ceased to have any use. It may indeed be mentioned 
that there are some who think that in all probability 
it serves some useful purpose. Appendicitis or in- 
flammation of the appendix is a very common disease, 
and there is reason for thinking that it has much 
increased in frequency during the last thirty years ; 
though there is clear evidence that it certainly existed 

170 



What Modern Surgery Can Do 

many years ago. We have very little certain know- 
ledge of the cause of appendicitis; but the popular 
idea that it is caused by the entrance into the 
appendix of a small portion of indigestible food such 
as an orange pip, is true of only a very small per- 
centage of the cases. All that can be said with 
certainty is that it is, somehow, associated with the 
presence of micro-organisms. 

Since appendicitis has been fully recognised, its 
surgical treatment has advanced greatly, so that at 
present it may be said that if treated sufficiently early 
the results are very excellent. Even yet the need for 
early treatment is not fully known, so that many 
patients seek treatment after the time when the 
operation would be most safely performed has passed 
by, and as a result the risk is greater. 

Skin-Grafting 

It has long been known that it is possible to a 
certain extent to transfer tissues from one animal to 
another, and nearly forty years ago Reverdin first 
commenced to employ skin-grafting. 

When a large ulcer is slow in healing its cicatrisa- 
tion may sometimes be hastened by skin-grafting. 
In the earliest form little snippets of skin were taken 
either from the patient himself or from others and 
were placed as little islets on the surface of the sore, 
and, when suitably cared for, from these islets pro- 
ceeded streams of skin which gradually covered over 
the whole ulcer. 

A marked advance on this was effected when 
Thiersch introduced his form of skin-grafting. In 
this method very thin slices of skin are taken by 

171 



What Modern Surgery Can Do 

means of a razor from other parts of the patient or 
from some one else, and these strips are placed side 
by side until the whole surface of the ulcer is covered. 
The slices of skin are extremely thin and include only 
a small part of the thickness of the skin. This is a 
much more rapid method than that which preceded 
it, and it is frequently employed at the present time. 

It is not essential that the transplanted skin should 
be derived from a human being ; a portion of the 
epidermis of one of the lower animals has been suc- 
cessfully transplanted on the human body. When 
the skin of a negro is employed for the skin-grafting 
of a white man, a very curious change occurs. For 
a time the patch of new skin is quite black, but later 
it gradually loses its pigment and the new skin is of 
the same colour as the rest of the body. Similarly, 
when portions of white skin are used to replace vacant 
patches of skin on the body of a negro, the patch of 
new white skin will take on the hue of the surrounding 
epidermis, and in time will become indistinguishable 
in colour. 



Replacement and Transplantation of Organs 

The nose is often lost, generally as the result of 
disease, but sometimes the loss is due to injury, and 
many years have elapsed since the first attempt was 
made to replace it. 

As Sir Charles Bell has said, the nose " is the organ 
which chiefly distinguishes the face of man from that 
of brutes, and the loss of a nose has much more 
effect on the general appearance than has the loss of 
an eye." Therefore the importance of the operation 
is not small. In some parts of India cutting off the 

172 



What Modern Surgery Can Do 

nose is not an unusual method of manifesting revenge, 
and this is the reason that operations for replacing a 
lost nose have been practised for many years there. 

In Europe the operation for replacing a lost nose 
was first attempted in Italy. The method employed 
was different from that used in India, so that there 
are two main operations for this deformity — one which 
is known as the Indian operation, and the other is 
commonly called the Taliacotian method, after Tagli- 
cozzi who devised it. 

In the Indian method a pear-shaped flap of skin is 
raised from the forehead and turned down so as to 
occupy the place of the nose, where it is made fast 
with stitches, and there it becomes adherent after a 
few days. In the Italian method the flap of skin is 
taken from the arm of the patient, the arm being 
fixed by an apparatus in such a position that it is 
possible to attach the flap of skin to the site of the 
nose while it is still fastened to the arm by a bridge 
of skin. Later this connection is severed. A fair 
measure of success has attended these operations if 
suitable cases are chosen, though the result never 
equals in appearance the original nose of the pos- 
sessors. 

In the chapter on Organotherapy an account has 
been given of a diseased condition called myxcedema, 
which results from atrophy of the thyroid gland, and 
it is there also mentioned that a similar condition 
follows complete removal of that gland. Treatment 
by administering an extract from the thyroid gland 
of the sheep gives very good results, but it has been 
suggested that it would be better if the patient could 
be given a new thyroid gland in place of the one 
lost. Transplantations of the thyroid gland of the 

173 



What Modern Surgery Can Do 

sheep have been made into the tissue underneath the 
skin of the patient, and when care has been exercised 
the wounds heal satisfactorily, but, so far as I know, 
in no case has the transplanted gland shown any 
indication of functional activity, for more or less 
rapidly it undergoes atrophy. 

Attempts have also been made to employ, not the 
thyroid gland of a sheep, but portions of the human 
thyroid which have been removed from another 
patient in whom the thyroid gland had undergone 
overgrowth, but here also the evidence in favour of 
the transplanted organ being of functional utility is 
very small. There can be no doubt that transplanted 
glands like this as a rule atrophy, and this is probably 
because the blood-vessels of the gland do not get 
sufficiently connected with the blood-vessels of the 
persons to whom they have been transferred to enable 
the glands to survive, so that the blood supply of the 
transplanted gland is insufficient. The principle of 
the treatment is no doubt perfectly correct, but at 
present the practical details are probably responsible 
for the result. There can be little hesitation in saying 
that in the future the method will be improved and 
will be successful. When this method of transplanta- 
tion of organs is successful, it is possible that some 
other organs, especially those provided with internal 
secretions, may be transplanted also. 

Paraffin Injections in the Treatment of a 
Misshapen Nose 

Within recent years attempts have been made to 
remedy the shapes of noses, especially those which 
are too hollow on the upper surface (saddle-back 

174 



What Modern Surgery Can Do 

noses, as they are often called), by injecting solid 
paraffin underneath the skin. A nose of this shape 
may be the result of injury or disease, or it may be 
the natural shape. If the skin is fairly loose over the 
depression the case will be suitable for the operation, 
which consists in the injection of solid paraffin under 
the skin into the hollow of the nose. Usually the 
paraffin is melted so that it is only just liquid as it 
enters the tissues, but some operators prefer to use 
paraffin in a solid condition, as it is safer. The greatest 
care has to be taken in ensuring that the paraffin is 
free from germs and that it is at the right tempera- 
ture. Also care must be taken that too much of the 
paraffin is not injected. It is better, on the whole, to 
inject too little rather than too much, for, if neces- 
sary, a little more can easily be added. The process 
generally does not require an anaesthetic for the pain 
is not great, but if required an anaesthetic can be ad- 
ministered. When the operation is performed only 
in suitable cases the results are good and the im- 
provement in the appearance may be very marked. 
There are also cases in which an excessive promi- 
nence of the nose can be removed, but the cases 
should be carefully selected before being submitted 
to operation, for it is much easier to do harm than 
good. 

Wiring Broken Bones 

When a bone is broken it is usually not difficult to 
"set it," that is to say, to place the fragments in the 
position in which they were before the bone was 
broken, and when this has been done and no muscle 
or other tissue is between the ends of the fragments, 
then the bone will unite readily and at the end of 

*75 



What Modern Surgery Can Do 

four or five weeks it will be possible to use the limb 
again. This is what may be called the usual or 
natural course of the healing of a broken bone, 
but it may happen that it is found to be impossible 
to get the two fragments in position ; and the X-rays 
may show that there is some displacement still. In 
cases such as these it is often advisable to operate 
in order to place the two fragments into the right 
position and to keep them there. The surgeon makes 
an incision down to the bone, removes any tissue 
which is interfering with the fragments coming to- 
gether, and then by one means or another fixes the 
two fragments so that they cannot move. The older 
method was to use silver wire which was passed 
through holes in the bone, first through one bone 
and then through the other, and then the ends were 
twisted together till the wire became fairly tight ; 
then the excess of wire was cut off and the wound 
was closed. The wiring of bones is in many cases 
very satisfactory, but it does not always succeed in 
holding the two fragments firmly together. Other 
methods have been devised to take the place of 
wiring. In one a hole is bored through both bones 
and a screw made of steel and covered with silver is 
put into the hole, and if the size has been carefully 
chosen and the hole has been correctly placed the 
two fragments will be held very firmly in position. 

A still further advance is the use of metal bars 
or plates, which are screwed to both bones and which 
hold them firmly together. These plates may be 
of silvered steel or they may be of aluminium. The 
most essential point in the operation is that it should 
be thoroughly aseptic, for even a very little sepsis 
may materially interfere with the success. Opinions 

176 




A Broken Knee-cap, soon after the injury 



This is a skiagram (X-ray photograph) of a broken knee-cap (patella); on the left are 
seen the two fragments widely separated. If treated without operation this injury 
usually leads to permanent lameness. 




A Broken Knee-cap United by Silver Wiri 



This is a skiagram of the same knee, showing the effect of " wiring " the broken knee- 
cap. The two fragments of the bone have been brought together, a piece of silver wire 
has been passed through them, and the ends of the wire have been twisted together. 
The wire is shown by the black line passing through the fragments. 



What Modern Surgery Can Do 

differ at present as to the frequency with which this 
operation for the treatment of simple fractures is 
required, except in the case of one bone, and that 
is the patella or .knee-cap. When the patella breaks 
across, the strong muscle of the thigh, which is 
attached to the upper fragment, pulls the two pieces 
far apart, and it is extremely difficult by means of 
splints and bandages to bring the two fragments to- 
gether and to hold them there. Therefore, unless the 
age of the patient or his health contra-indicates an 
operation, it is advisable to operate on fracture of 
the patella. Many methods have been devised, and 
they all have for their object the bringing the two 
fragments together and holding them in apposition, 
wires being made to pass from one fragment to the 
other. When care is taken to avoid sepsis the re- 
sults are all that can be desired, for the two fragments 
unite by bone tissue and the bone is as strong as 
it was before. 

Sometimes when a simple fracture of a bone has 
been put up in the ordinary way and has been allowed 
to remain in splints for five or six weeks and then 
is taken down, it may happen that, to the surgeon's 
disappointment, it is found that the bones have not 
united, and that even keeping the limb in splints for 
another month or two will not result in the healing 
of the bone. This condition is called " ununited 
fracture," and until the introduction of the antiseptic 
method it frequently gave a great deal of trouble to 
surgeons. Various methods were adopted to induce 
the two fragments to join, but rarely did they prove 
successful. In cases such as these all surgeons are 
agreed that an operation must be performed. The 
details will necessarily vary according to the special 

177 M 



What Modern Surgery Can Do 

method employed, but the general principles will be 
the same. An incision is made so as to expose the 
site of the fracture ; a small portion of each fragment 
will be removed so as to freshen the surface, and then 
by means of wires, or by screws or by plates, the two 
pieces of the bone will be fixed together. Here also 
the very strictest attention to asepsis is essential if 
successful results are to be obtained. 



178 



CHAPTER XVII 

THE VALUE OF DRUGS 

At the present day the opinions which exist even 
amongst medical men as to the value of drugs differ 
greatly from one another. While some consider that 
drugs are of the greatest importance in the treatment 
of disease, others look upon them as almost valueless, 
and it is certain that the recent great advances in 
surgery have done much to assist in the neglect 
of the use of drugs in medicine. For it has been 
found possible by surgical operation to cure many 
conditions which at one time could only be treated by 
means of medicine, and even then the results were 
often unsatisfactory. 

There was a time when the belief in the efficacy 
of drugs was very great indeed. It was thought 
possible to cure any and every disease by suitable 
medicines or applications. Any one who reads the 
older works on materia medica, as the study of drugs 
is called, will be much surprised at the claims made 
on behalf of many of the substances dealt with. No 
condition was considered to be irremediable, but 
each and every disease had its appropriate remedy. 

It will be clear to any careful reader of old works 
on drugs that many of the claims made for sub- 
stances now almost forgotten must be utterly ill- 
founded ; otherwise it is intensely unlikely that the 
drugs would now be neglected. We have records of 

179 



The Value of Drugs 

the exact treatment given to many persons in the 
eighteenth and in the early part of the nineteenth 
century, and it is surprising to medical men of the 
present day that so much treatment by medicines 
was considered necessary. At that time it was hardly 
recognised that there is a vis medicatrix naturcz, or 
a healing power of nature, and that the body is cap- 
able of curing itself to a very great extent, just as 
a lifeboat has the power of righting itself even when 
it has been overturned. 

There is, of course, a limit to the self-healing 
powers of the human body, and sometimes its well- 
meaning attempts at cure serve but to aggravate 
the disease. Even after allowance has been made 
for exaggeration in the claims in favour of the value 
of drugs and for the natural healing powers of the 
body, it would be rash to assert that our predecessors 
were utterly wrong in all their ideas of treatment, 
that every claim for every drug was founded on fiction 
and not on fact. There is a solid foundation for the 
employment of drugs in medicine, and it is probable 
that at the present time they are unduly neglected. 
In the use of drugs, however, there is an error into 
which those treating disease are liable to fall. The 
symptoms are mistaken for the disease, and the 
physician in the past was, we cannot help thinking, 
a little too prone to be satisfied with treating the 
symptoms. The symptoms are merely the outward 
expression of the within-lying disease. When a person 
has scarlet fever the disease really consists in an in- 
vasion of the body by the microbe of scarlet fever, 
and the symptoms — the raised temperature, the red- 
ness of the skin, the pain, and the soreness of the 
throat — are merely the results of the invasion of the 

180 



The Value of Drugs 

body by the microbe, the outward expression of the 
disease. In treating a malady the aim should always 
be to deal, when such is possible, with the essential 
cause, and the symptoms should be treated only in 
so far as they are causing the patient unnecessary 
or excessive pain or discomfort. 

When a patient has bronchitis one of the most 
striking symptoms is cough. This symptom may be 
extremely trying to the patient, but it arises really 
from an effort of the body to remove the cause. It 
is the accumulation of mucus in the air tubes that 
is making the patient cough, and the cough is in- 
tended to remove this mucus from the lungs. If, 
therefore, treatment is given merely to suppress the 
cough, it may do harm, for it may interfere with 
the natural attempt to remove the morbid secretion 
from the lung, and this is why patent medicines for 
a cough taken without medical advice so often prove 
highly injurious. They may indeed stop the cough, 
but they may, by stopping the cough, allow the 
mucus to accumulate in the lungs and thus make the 
disease greatly worse, or they may even lead to a 
fatal issue. Sometimes, indeed, it may be desirable 
to treat symptoms, and we may take the same illustra- 
tion as before. In certain cases it may well happen 
that the violence of the cough may be in excess of 
what is really required, and as a result the patient 
is unnecessarily troubled. In a case like this a seda- 
tive to allay the cough or diminish its violence may 
be perfectly reasonable, but it needs knowledge and 
skill to appreciate the states in which the sedative 
should be given and those in which it must be care- 
fully withheld. 

Again, a symptom such as pain may be doing 

181 



The Value of Drugs 

absolute harm by interfering with sleep, and the loss 
of sleep may risk the patient's life. Even in the 
treatment of pain, however, the greatest care must 
be used in giving sedatives, for it frequently happens 
that pain is an indication of serious disease, and if 
the pain be obscured by the indiscriminate use of 
sedatives, the diagnosis may be rendered difficult 
and the progress of the disease obscured. We may 
take as an example of this the pain of appendicitis. 
Here the pain is an indication of severe affection of 
the appendix, and in all probability it will require 
an operation sooner or later. If this pain be drowned 
by sedatives, one of the most valuable indications 
of the progress of the disease will be lost, and should 
a surgeon be called in for the purpose of diagnosing 
the disease and deciding on the desirability of an 
operation, his task of diagnosis will be immensely 
increased. In these and many similar cases the 
treatment of the symptom is much less important 
than the treatment of the cause, for usually if the 
cause be removed the symptom disappears almost 
immediately. When, however, as not very rarely 
happens, the cause is undiscoverable, the treatment 
must consist largely in the management of the 
symptoms, but always regard must be paid to the 
need for not interfering unnecessarily with symptoms 
which may have a beneficial action. 

As to the value of certain drugs there can be no 
question. To give an example known to every one, I 
may quote quinine. The value of quinine in malaria 
rests on so sure a foundation that no one will venture 
to dispute it. I will give an early instance. In 1845 
the British Government sent an expedition up the 
Niger. It was partly scientific in nature, but it was 

182 



The Value of Drugs 

also intended to assist in the formation of trading 
colonies up the river. A large number of the members 
of the expedition died of malaria, and many more were 
attacked severely by the disease, so that the formation 
of the trading stations became practically impossible. 
In this expedition no special precautions were taken 
to prevent the occurrence of malaria amongst the 
crew, and the result was as I have mentioned. 

In 1854 another expedition was sent up the same 
river by the British Government, but it was arranged 
that the surgeons of the expedition should administer 
quinine every day to all its members, with the result 
that no deaths occurred and that the expedition re- 
turned having had a very small amount of sickness on 
board. 

We now know how quinine acts. It exerts an 
antiseptic action on the germ causing malaria, the 
Plasmodium malaria, and if taken to prevent malaria 
it can act as soon as the germ enters the blood ; but 
the fact of the value of quinine was known long 
before we understood its mode of action. A certain 
number of other examples might be cited, but it 
must be acknowledged that the cases in which a drug 
acts as promptly and as certainly as quinine does in 
malaria are few. Nevertheless, though the degree of 
certainty is slighter, many instances might be quoted 
where a drug has a definite invariable action on a 
certain organ, structure, or tissue, and the physician 
may rely with confidence on the drug when he needs 
it. Some of the uncertainty which exists as to the 
value of a drug may reasonably depend on the diffi- 
culty of obtaining it in a state of purity, for many 
substances are habitually adulterated. One bark is 
replaced by another, or one leaf is supplied in place 

183 



The Value of Drugs 

of another closely resembling it. Most of these 
substitutions are for the sake of extra gain, but on the 
genuineness of a drug may depend the health or the 
life of many patients. It is therefore the duty of the 
State to see that drugs are genuine and pure. 



Patent Medicines 

One of the most wonderful facts in connection with 
medicine is the great faith which so many people have 
in secret remedies, or as they are called in this country, 
"patent medicines," because they bear a Government 
stamp. Many a man, who has little belief in the 
knowledge or skill of doctors, will pin his faith to some 
patent pill or powder. He will doubt the ability of a 
doctor who for years has studied medicine and surgery, 
and who has the opportunity of examining him so as 
to diagnose the disease, and he will put his trust in a 
patent medicine, making his own diagnosis and choos- 
ing his own treatment. I would not for one moment 
deny that many secret medicines have proved useful ; 
it would be strange if they had not, for they contain 
only the ordinary drugs which are used in prescriptions. 

The real charm lies in the fact that the composition 
of the patent medicine is unknown, and therefore it 
is thought that it may contain some rare and unknown 
drug, possessing marvellous properties. If every 
patent medicine were required to bear its formula 
on the bottle or box containing it, most patent medi- 
cines would lose nine-tenths of their reputation. It 
is interesting to note how much the advertisements 
of secret remedies resemble each other. Often they 
run on lines such as these : — 

The rare plant has been found in the pathless 

184 



The Value of Drugs 

forests of Brazil, and the half-dying traveller as he 
sinks to the ground almost unconsciously picks and 
eats some brilliant flower or shining leaf : he cares 
not if it should prove poisonous, for he feels that his 
strength is spent and that he must die. Yet within 
a few seconds his heart is beating with greater force ; 
his eyes, dim with the approach of death, are become 
once more clear ; his mind, wandering with the de- 
lirium of fever, returns to him ; his tired limbs receive 
an immediate accession of strength, and he feels, nay 
more, he knows, that he is saved. With feeble hands 
he hurriedly gathers more of the brilliant flowers, 
or of the shining leaves, as the case may be. He 
carries them to his mouth and he eats them raven- 
ously, and then he slowly sinks into a long dreamless 
slumber. Hour after hour he sleeps on, and at length 
he awakes and he is well. His mind is clear ; all his 
aches and pains are gone ; and as he rises to pursue 
his journey, in thankfulness for his recovery he raises 
his hand to heaven and registers a vow that when 
he reaches civilisation he will return with help and 
will gather loads of the precious flowers (or leaves), 
and he will take no rest till he has made known to 
suffering humanity the precious balm that he has 
discovered. And, in conclusion, he informs all and 
sundry that he has determined to devote the re- 
mainder of his days to spreading abroad the glad 
tidings and to purveying to the said suffering humanity 
the healing drug at almost cost price, which proves 
to be three shillings and ninepence for a four-ounce 
bottle, or ten shillings for a big bottle containing four 
times the quantity in the other. 

Sometimes the story varies a little. It may be the 
traveller aforesaid was not half dying, but was travel- 

i8g 



The Value of Drugs 

ling in good health through the pathless forests of 
Paraguay, when he finds an aged squaw lying on the 
ground far from her village. In this case it is the 
aged squaw who is half dying, and the traveller, 
touched with compassion, offers her food and drink. 
Refreshed with this timely succour, the aged squaw 
tells her story. She has been turned out of her 
village, partly because she is old and useless, and 
partly because she had been suspected of witch- 
craft, and partly because she has a knowledge of 
the virtues of herbs which she may have used 
sometimes for the detriment of her enemies, and 
she has been left to live in the forest as best she 
may or to die of hunger or of wild beasts. The com- 
passionate traveller marvels at the brutality of the 
villagers, and tends with care the aged squaw until 
in a few hours or days she dies. But, ere she dies, 
in feeble accents and with halting breath she imparts 
to him a great secret. A herb, a specimen of which 
fortunately grows close by so that she can point to 
it, possesses marvellous curative properties for all 
the ills that flesh is heir to ; and she tells him all it 
can do ; how it should be prepared and how taken. 
At the very moment she has finished supplying him 
with these important particulars, she falls back dead ; 
and this traveller vows that (provided the plant has 
the virtues ascribed to it) her death shall not have 
been in vain, for he will spread far and wide the fame 
of the virtues of the plant, made known to him by 
the aged squaw. And so he does, and this also is 
three shillings and ninepence a bottle, or ten shillings 
for a big bottle containing four times as much as the 
other. 

Sometimes it is not a traveller at all who makes the 

186 



The Value of Drugs 

great discovery. It is a man who had a great-great- 
aunt, and this aunt had lived to the age of no years, 
to the wonder and envy of all her friends and 
relations. This aunt had had a great reputation for 
administering to the ailments of the poor of her 
neighbourhood, and she always gave them twenty 
drops of a bright brown liquid which she prepared 
herself. It did not seem to matter much what was 
wrong with any of the poor, they always had the 
twenty drops of the bright brown liquid — whether it 
was mumps or measles, paralysis or spasms — and the 
result was always wonderful. To show her bona 
fides the old lady often took some of the drops 
herself, and it was the popular idea that it was to 
these very drops she owed her great age and good 
health. As she lay a-dying — for she did die, though 
I cannot say why — she tried to speak to her great-great- 
nephew, but in vain ; and she could only point with a 
shaking hand across the room. After her death her 
nephew tries to imagine what her meaning was when 
she pointed, and at last he decides that she wished to 
point to an old, old, oak bureau. This he searches 
for some hidden treasure, but he searches in vain. 
Again and again he returns to the fruitless quest, and 
he is about to give it up in despair when his foot 
catches in the leg of the old, old, oak bureau, and over 
it falls. The fall is too much for it — it bursts to pieces, 
and a hidden drawer is revealed. With frantic haste 
he opens the drawer, hoping to find many guineas or 
bank notes, but no ; in it is only a single sheet of 
paper. He seizes it, and scans it with an anxious eye. 
The ink is faded and the writing is in an antique 
hand, but he sees enough to know that here he has 
the recipe for the bright brown liquid ; and though 

i8 7 



The Value of Drugs 

naturally somewhat disappointed at first, he finds in 
time that his aunt has left him what is of more value 
than money — a remedy to cure all maladies, from 
mumps to measles, as mentioned already. By its aid 
he can alleviate the woes of the human race, and in 
order that there should be no mistake about the 
purity of the drugs, he does not publish his aunt's 
recipe, but he has it prepared at what is practically 
cost price, and he offers it to suffering humanity at 
three shillings and ninepence per bottle, and a re- 
duction on taking a quantity. 

Patent medicine vendors would not publish such 
tales as these (except, of course, when the tales happen 
to be true) unless they thought that the strange 
manner in which they had obtained the secret of the 
medicine would recommend it to the public. It is the 
wonderful way in which the secret has been learned 
that makes its value. This reasoning may be a little 
illogical, but those who put their trust in patent 
medicines seldom care much for logic. 

What is the remedy ? The simplest and fairest 
method, in my opinion, is not to forbid by law the sale 
of patent medicines, but to make it compulsory that 
every patent medicine should bear on its bottle or box 
a correct statement of its constituents. Then every 
purchaser would know what he was buying, and he 
would not be deluded by the charm of the unknown. 

There is another evil almost as great as that of patent 
medicines. It is the practice of self-drugging. Many 
men and women consume large quantities of antipyrin 
and of phenacetin and of many other similar drugs. 
They buy them in the tablet form, and take one or 
more tablets whenever they feel so inclined. Immense 
harm is done by this practice, for the persistent and 

188 



The Value of Drugs 

indiscriminate use of these drugs affects injuriously 
many tissues of the body and renders those who 
indulge in them peevish and restless and incapable of 
sustained effort. Unfortunately the practice appears 
to be spreading, perhaps because the facilities for it 
are increasing. Probably the most harmful form of 
self-medication is the custom of taking narcotics. 
Opium, morphia, chloral, and cocaine are the chief 
drugs of this class which are taken. Unfortunately, 
only too many commence to take these poisons 
without understanding that once the practice has 
been begun it degenerates rapidly into a habit, from 
which it is almost impossible to escape by any effort 
of the will. By the aid of others the attempt to re- 
linquish the taking of morphia or one of the other 
drugs mentioned above may prove successful, but it 
is only with great difficulty. Before any one com- 
mences the practice of taking any narcotic, whether 
it be for pain or sleeplessness, he should realise that 
he is about to become a slave, and that release from 
this servitude is unlikely. 



189 



CHAPTER XVIII 

ORGANOTHERAPY 

From a very early time there has been a tendency to 
ascribe certain virtues to certain organs of the body, 
and the existence of such a belief is not confined to 
primitive races, but it can be seen even in highly 
civilised peoples of the past and of the present day. 
It follows almost naturally as a corollary to such a 
belief that the administration of a preparation of any 
organ might be expected to be beneficial in a case 
where the special quality supposed to exist in it was 
iacking. As bravery was believed to be connected 
with the heart, savage warriors imagined that to eat 
the hearts of their enemies would increase their own 
courage. From a custom such as this it was an easy 
step to imagine that the administration of the liver, 
for instance, of an animal might be of use in disease 
of the liver in man. We find in the works of Celsus 
and Dioscorides recommendations for the employ- 
ment of various organs derived from animals for the 
treatment of disease of those organs in man. The 
lung of the fox was advised for shortness of breath, 
for the fox is able to run long distances at a high 
speed ; the brain of the hare for tremors, and rennet 
for disorders of the stomach. Many of these and 
similar remedies continued in use until comparatively 
recently, but about the beginning of the nineteenth 

190 



Organotherapy 



century they were almost all discarded from the 
pharmacopoeias, and we find hardly any example of 
their employment until, about 1840, in consequence 
of advances in our knowledge of the physiology of 
the stomach, an artificial gastric juice containing 
pepsin was prepared from the stomach of the pig for 
use in dyspepsia ; and if suitably prepared and suit- 
ably administered, it does prove useful in certain 
forms of this disease. 

Similar preparations have been prepared from 
the other great digestive organ, the pancreas, and 
pancreatic juice is widely used for some forms of 
indigestion, but even more for the predigesting of 
food. By this is meant the subjecting of some food 
to the action of an artificial pancreatic juice (gener- 
ally prepared from the pancreas of the pig) ; then the 
food is taken, and as it has already undergone partial 
digestion, the digestive organs of the patient are not 
so severely taxed. Usually milk is the food treated in 
this way ; to a certain quantity of milk some artificial 
pancreatic juice is added, and the mixture is kept at 
the temperature of the human body for a certain time, 
with the result that the ferments of the pancreatic 
juice act upon the constituents of the milk in very 
much the same way as the ferments of the human 
pancreatic juice would have acted if the milk had 
been swallowed. The method is certainly of value, 
but it has its limitations, and usually it is found better 
not to allow the predigestion to proceed very far, 
otherwise the product may prove too unpalatable to 
be taken readily. 

The theory of the use of pepsin and of pancreatic 
juice is very simple, but now we have to consider a 
more complex example of the treatment of disease by 

191 



Organotherapy 



the administration of organs, or organotherapy as it 
is called. 

The secretions of the glands of the body are for the 
most part poured out into the cavities of the body, 
there to serve some useful purpose, as, for instance, 
the saliva is poured out into the mouth to assist in the 
digestion of the food. 

For many years, however, we have had reason for 
thinking that several glandular organs of the body 
secrete substances which are not poured out by ducts, 
but are absorbed by the blood-vessels and so pass 
straight into the circulation, and thus are able to 
perform the functions for which they are intended. 
These are called "internal secretions," and modern 
physiology attaches great importance to them. Re- 
cently it has been recognised that certain affections of 
the body may be caused by absence or disease of some 
of these organs, and the first organ which was con- 
clusively shown to have an internal secretion was a 
gland in the neck which is called the thyroid gland. 

Every one knows that in several countries, especi- 
ally Switzerland and Norway, there are certain dis- 
tricts in which a large proportion of the inhabitants 
are affected with a prominent swelling of the throat 
called " Goitre." This condition occurs also but to 
a much less extent in England ; and as it is especially 
common in Derbyshire, it is frequently called the 
" Derbyshire neck." The disease is very old, for 
it was well known to the Romans and it is mentioned 
by Juvenal. It is due to an enlargement of a gland 
which is situated in the front of the throat immediately 
in front of and to the side of the air-tube. 

It is called the thyroid gland, and until recently 
nothing was known of its function. At last, in 1883, 

192 



Organotherapy 



it was noticed by Reverdin that some patients from 
whom the whole of the enlarged goitrous thyroid 
gland had been removed suffered from a group of 
curious symptoms which were evidently connected 
with the removal of the gland. The symptoms are 
these : the patient experiences at first a feeling of 
lassitude, and this tends gradually to increase till even 
the slightest exertion is wearisome ; active exercise 
and work are given up, and the existence of the 
patient is almost entirely sedentary. A feeling of 
coldness tends to develop, and later on the tempera- 
ture may be a degree or two below the normal. The 
tissues beneath the skin gradually become distended 
by a gelatinous liquid, so that the features become 
much more rounded and the appearance of the face 
is greatly altered. Perspiration is diminished, with 
the effect that the skin becomes very dry. The mental 
processes become slowed, and the mind is sluggish 
both in understanding facts and in acting on them. 
It was soon seen that these symptoms were identical 
with those which had recently been described by Ord 
and named myxcedema, and it was known that in 
myxcedema the thyroid gland was extremely shrunken 
and atrophied, and therefore it was clear that some- 
how the removal or atrophy of the thyroid gland 
caused the appearance of these symptoms. It was 
thought by some that the symptoms might be due to 
some interference with the nervous system during 
the operation for the removal of the thyroid gland, 
but evidently this could not be the correct explana- 
tion, for the symptoms were in great part removed 
when an extract made from the thyroid gland of a 
sheep was injected under the skin of these patients. 
It is clear, then, from these and many other ob- 
193 N 



Organotherapy 



servations that the thyroid gland secretes a substance 
which is carried away by the blood-vessels and has 
a very important effect on the general mental and 
physical well-being. Evidently the thyroid has an 
" internal secretion." It was known that in many 
places, both in goitrous countries and also in countries 
where goitre is extremely rare, that children are oc- 
casionally born who develop exceedingly slowly. 
These are called a cretins." The name " cretin " is 
applied to two conditions which are really different. 
In one the lack of development is accompanied by 
an enlarged thyroid gland ; in the other the thyroid 
gland is absent. To the members of this latter class 
the name of " sporadic cretin " is given, because the 
condition may occur in districts which are not 
goitrous. 

The u cretin " of a family may at the age of twenty 
only equal in height one of his brothers a dozen or 
sixteen years younger ; and his mental development 
is retarded to an equal extent, for he will be unable 
to read, and indeed he may have no knowledge of 
the alphabet, and speech may be badly developed. 
The features are rounded and coarse, and in fact 
the patient is a representative on a small scale of a 
person suffering from myxcedema. In these cretinous 
children the thyroid gland is absent. So we are 
able to explain this form of cretinism by the con- 
genital absence of the thyroid gland. 

If this explanation were correct, it might be pos- 
sible to effect some improvement in these children 
by means of administering an extract from the thyroid 
gland. If the case has not been left too long un- 
treated, it is found that the administration of an 
extract of the thyroid gland in a suitable dose may 

194 



Organotherapy 



lead to a rapid increase in the rate of growth of 
the patient, and the mental improvement is generally 
equally well marked. These beneficial effects are 
more noticeable the earlier in the life of the patient 
the thyroid extract is given. 

When the idea of administering extract of the 
thyroid gland in myxcedema first arose, it was 
thought necessary to inject it under the skin, but 
later it was suggested that the same result could be 
obtained more simply by giving the extract of the 
thyroid gland, or even the thyroid gland itself, by 
the mouth. Indeed in an early stage of evolution 
the thyroid gland had a duct by which the secretion 
was poured into the throat, and a knowledge of this 
fact might have suggested earlier that giving the 
thyroid gland by the mouth might be quite as effica- 
cious as injecting it under the skin. At present 
thyroid extract is always given by the mouth, and 
it has proved of great value in myxcedema. 

It may be taken therefore as proved, that the 
thyroid gland secretes a substance which is absorbed 
into the blood-vessels and so is carried all over the 
body, and that this substance is of so great import- 
ance to the animal economy that its absence is 
followed either by lack of development or by a 
marked degradation of the vital processes both of the 
body and mind. 

The thyroid gland was the first known example 
of an organ forming an internal secretion ; and even 
up to the present time it has remained the most 
striking instance of this. 

The extract of the thyroid gland has also been 
used for other diseases. Thus, in certain maladies 
of the skin it seems to have a very definite effect, and 

195 



Organotherapy 



in several other conditions the extract of the thyroid 
gland has proved to be of service. 

Another instance of an internal secretion is afforded 
by the suprarenal gland. This is a small body situated 
at the upper end of each kidney though not connected 
with it. Even now, after much investigation, we know 
but little of the action of this gland, but we do know 
that when the gland is diseased, and especially when 
the disease is far advanced, so that hardly any healthy 
tissue remains, a curious condition of the body 
occurs, in which the patient becomes very weak ; he 
is troubled with vomiting and anaemia, and he shows 
also a still more striking sign, for the skin becomes 
of a curious coppery tint. This disease is known as 
" Addison's disease," and though we cannot account 
for the symptoms we feel quite sure that there is an 
association between the atrophy of the suprarenal 
gland and these troublesome symptoms, and the evi- 
dence which we possess goes to show that the gland 
acts, not through the nervous system as was at first 
suggested, but through the formation of an internal 
secretion. 

That an extract of the suprarenal gland has a 
powerful action on the body there can be no doubt. 
It causes strong contraction of all the smaller blood- 
vessels, and thus it is of much use in preventing 
bleeding from the smallest blood-vessels, and the 
extract has also proved of value in cases where 
the blood pressure is very low, for it can raise the 
blood pressure by contracting the peripheral vessels. 
It is worthy of note that if extracts prepared from 
the suprarenal gland be administered in too large 
a dose or for too long a time serious symptoms may 
result. 

196 



Organotherapy- 
other organs, such as the liver and the pancreas, 
also probably possess internal secretions in addition 
to the external secretion of the bile and the pancreatic 
juice, and there is some evidence that extracts made 
from these glands are of value in some diseases of 
those organs. 

The subject is new, but it is not improbable that 
in the near future we shall possess sufficient know- 
ledge of the internal secretions of the various organs 
to enable us to utilise them in the treatment of 
disease ; but I have said enough to show that, in 
some cases at least, there is a solid basis, both theoreti- 
cal and practical, for the employment of organs or 
extracts made from them in the treatment of disease. 



197 



CHAPTER XIX 

MALARIA 

Malaria is a convenient generic name for a number 
of diseases, characterised by a curious sequence of 
events ; an attack begins with a shivering fit, or 
" rigor " as it is termed, and this is followed by a 
a hot stage " with a high temperature, and then comes 
the " sweating stage/' with profuse perspiration, and 
a return of the temperature to the normal. A similar 
attack recurs at regular intervals, sometimes every 
day, sometimes there is an interval of a day or even 
of two days, and to these varieties the names of 
quotidian, tertian, and quartan are given. Ague is 
one of the milder forms of malaria, and like all 
the less severe varieties of the disease it has a distinct 
interval with absence of fever between two attacks ; 
these are called intermittent fevers. When the tem- 
perature falls after an attack but not to the normal, 
the fever is described as " remittent." 

Malaria has been known from a very early period 
of the history of the world, and in most countries it 
has been seen at one time or another. Of its import- 
ance there can be no question, for in many regions 
of the globe almost two-thirds of the total mortality 
is caused directly or indirectly by malarial fevers and 
their allied disorders. Dr. Cornish of Madras has 
said that " Fevers in one form or another destroy 
twice as many people in India as small-pox, cholera, 
and all other epidemic causes put together." The 

198 



Malaria 

cause and control of malaria and the other diseases 
allied to it are therefore of great moment to all con- 
cerned with the welfare of the countries where these 
maladies are rife. 

Until some twenty years ago the true cause and 
mode of spread of malaria were utterly unknown, and 
it was looked upon as the direct result of certain 
climatic conditions. The typical requirements for 
the production of malaria were considered to be heat, 
moisture, and the decomposition of vegetable matter. 
In low, wet,- and warm localities much malaria is 
generally found, and that a marsh was looked upon 
as furnishing the essentials for the production of 
malaria is attested by some of the names given to the 
disease: it was often spoken of as " paludal fever," 
and the unknown poison which produced it was 
called M marsh miasm." It was recognised that a Jake 
did not give rise to the disease, and even a marsh 
when well flooded with water did not appear to be 
prone to cause malaria, but the condition most favour- 
able was a marshy district which was half dried lying 
under a tropical sun. That such a circumstance 
would favour malaria was well shown in the district of 
Burdwan in Bengal. The soil was dry and it had 
been a healthy district, until gradually the drainage 
of the country was interfered with by the silting up 
of the natural and artificial outlets for the water, so 
that the soil became water-logged ; and then it was 
not long before malaria became very prevalent and 
the death-rate rose greatly. 

Such are the conditions which appear to be 
specially favourable to the production of malaria, but 
they are certainly not essentials. In 1794 the summer 
was very hot and dry, and the British army which 

199 



Malaria 

was acting in Holland against the forces of the French 
Republic had suffered but little from disease. In 
August it encamped at Rosendaal and Oosterhout, 
where there was a sandy plain with a perfectly dry 
surface, supporting no vegetation except some stunted 
heaths. However, a few inches below the surface 
there was water, but it was clear and apparently fit 
for drinking. In this soil, where no decomposing 
vegetable matter existed, malarial fever soon showed 
itself, and prevailed to a great extent. 

In the year 1809 several regiments of the British 
army in Spain encamped in a hilly ravine down which 
had flowed a stream. This, however, had ceased to 
flow, but here and there among the rocks still remained 
pools of water, so pure that the soldiers were anxious 
to camp near them, but before the next morning 
several men were seized with malarial fever. 

Dr. William Ferguson, who recorded the incident, 
says : " Till then it had always been believed amongst 
us that vegetable putrefaction (the humid decay of 
vegetables) was essential to the production of pesti- 
ferous miasmata ; but in the instance of the half-dried 
ravine before us, from the stony bed of which (as soil 
never could lie for the torrents) the very existence 
even of vegetation was impossible, it proved as pesti- 
ferous as the bed of a fen/' 

After the battle of Talavera, when Wellington de- 
feated the French under Victor, the British army was 
compelled to retreat by the approach of another 
French army under Soult ; it followed the course of 
the Guadiana river till it reached the plains of 
Estremadura. The country was extremely dry from 
want of rain, so that all the streams and even the 
Guadiana itself had ceased to flow, and they formed 

200 



Malaria 

only lines of detached pools in the river beds, yet the 
troops suffered from malaria "of such destructive 
malignity that the enemy and all Europe believed that 
the British host was extirpated." 

It was clear from these and many other similar 
histories that vegetable decomposition was not 
essential to the production of malaria. 

Many more facts could be quoted to show that 
observers more than a century ago had noticed that 
malaria might occur in conditions very different from 
those prevalent in tropical marshes. For malaria also 
occurs in temperate climates, and it was formerly 
widely prevalent in the British Isles, especially along 
the eastern coast of England, and at one time it 
occurred in London. It is endemic in the moors and 
marshes of Oldenburg, Hanover, and Westphalia in 
Germany. In Holland, Groningen, Friesland, and 
Zealand suffer much, and it occurs as far north as the 
central depression of Sweden, especially on the shores 
of Lake VVener. Its former prevalence in England is 
shown by the fact that both James I. and Oliver Crom- 
well died from ague. 

Malaria may, as we have seen, exist under many 
conditions, and in many parts of the globe, but it has 
certain limitations. Although it may occur as high as 
7000 feet above the level of the sea, it is quite excep- 
tional for it to attack persons raised even a few feet 
above the level of the ground. In some countries the 
houses are built upon piles, and those who sleep in 
them are not liable to be attacked, and the same im- 
munity is secured by the natives of South America by 
sleeping in the branches of trees. A small extent of 
open water is sufficient, in most cases, to keep the 
disease away, so that men on ships, even a quarter of 

201 



Malaria 

a mile from a malarious shore, generally escape. A 
belt of trees or even a high wall has appeared to keep 
off malaria. In Guiana we are told that the settlers 
can live fearlessly and unhurt, close to the most pesti- 
ferous marshes and to leeward of them, provided that 
a screen or belt of trees be interposed. However, a 
wind blowing from a malarious district may carry the 
disease to spheres previously free from the disease. 
A much more important limitation concerns the time 
of day. It is well known that even the most dangerous 
districts are practically safe while the sun is up, but 
that danger arises as the sun sets, and so it happens 
that when the crew of a ship lying off a malarious 
coast land during the daytime but always return to 
the ship to sleep, they do not become attacked with 
the disease, but if they sleep on shore they are gener- 
ally affected. In 1766 the warship Phoenix was re- 
turning from the coast of Guinea. The officers and 
the men were perfectly healthy till the ship touched 
at the island of St. Thomas. Here nearly the whole 
crew went on shore, and all of these except sixteen 
returned to the ship to sleep. Of these sixteen every 
one was attacked with fever and thirteen of them died. 
The rest of the crew consisted of 280 men, and they 
went in parties of twenty or thirty on shore during 
the daytime and rambled about the island hunting 
and shooting, but they returned to the ship at night, 
and not one of them who so returned suffered in the 
slightest. 

Malaria is very liable to appear in tropical countries 
when forests have been cut down and agriculture has 
been started, but it tends to disappear later, when the 
country is thoroughly cultivated. 

The value of cinchona bark for the treatment of 

202 



Malaria 

malaria in all its forms has been known now for 
nearly three hundred years. Its practical utility was 
acknowledged by all, even while the most varied 
theories existed as to the cause of the disease, and 
mode of action of the drug. Although we now know the 
true etiology of malaria, and can do much to prevent 
the appearance of the disease in districts where it has 
been endemic hitherto, cinchona bark and its deriva- 
tive, quinine, provide still the best method of treating 
malaria in all its forms. There is no well-authenti- 
cated record of the use of " Peruvian bark," as it was 
first called, before the year 1638, when the Countess 
del Chinchon, the wife of the Viceroy of Peru, was 
cured of a malarial fever by the use of the bark ; and 
the bark owes its name of cinchona to this fact. 

Some have doubted this etymology of the word, 
denying even the existence of the Countess del 
Chinchon. The native Peruvian name for the tree is 
said to be Kina or Kinken, and the name cinchona is 
said to be derived from this. It is also said that the 
natives do not value the bark for intermittent fevers, 
but have a prejudice against it, and that a native has 
been seen dying with malaria and bearing on his back 
a load of the bark and yet unwilling to touch it or 
unaware that it would cure him. 

When the use of Peruvian bark was first introduced 
into Europe, it met with violent opposition even from 
physicians of high authority. Sydenham, who was the 
greatest English physician of the seventeenth century, 
did much to promote its adoption in this country, 
and gradually it attained to the highest position in the 
treatment of malaria. Quinine was separated from 
cinchona in 1820, and has to a very large extent 
replaced the bark and its preparations. 

203 



CHAPTER XX 

THE POLITICAL IMPORTANCE 
OF MALARIA 

The advance or decay of a nation is generally attri- 
buted in historical works to such obvious causes as 
wars or religions, and equally widespread is the idea 
that by passing laws it is possible to elevate a people. 
Sometimes we find that progress is ascribed to an 
individual leader, without whom, we are told, no 
progress would have been made. I have no wish to 
belittle the importance of all these influences in assist- 
ing or retarding the national advance of a people, 
for they are, undoubtedly, very important factors 
in the progress of a nation, and the advent of a 
leader may suffice to turn the scale one way or the 
other. There is a very definite popular belief in the 
efficacy of legislation to determine the welfare of a 
country; but, though the passing of laws may have 
an indirect effect in the matter, the direct effect is 
very much less than is usually imagined. 

Races of animals disappear. In the ages of the 
past innumerable kinds of animals have lived their 
lives and have lasted for many thousands, perhaps 
millions of years, and yet, as the records of the rocks 
tell us, they have come to an end. Within more recent 
time, indeed, man has been one great cause of the 
disappearance of species of animals, but we may be 
quite sure that he has only been one cause, for, ages 

204 



The Political Importance of Malaria 

before man dwelt on the earth, there occurred the 
same extinction of various races of animals. May it 
not well be, therefore, that what holds good for the 
lower animals may be applicable to man ? Now, the 
destruction of a whole race of animals is always de- 
pendent, if we put aside the destruction caused by 
human agency, on want of food, climatic conditions, 
or disease. That want of food may cause widespread 
destruction of animals is known to all, and especially 
when combined with adverse climatic conditions, the 
destruction may be enormous. Darwin estimated 
(chiefly from the reduced number of nests in the 
spring) that the winter of 1854-55 destroyed four- 
fifths of the birds in his grounds. 

Of this loss of food man, without doubt, is often 
a cause, and so he is, in this way, indirectly a cause 
of the disappearance of animals, but he is only one of 
many causes. That disease may almost destroy a race 
of animals is not less clear, for we know of many 
most virulent epidemics amongst animals. If these 
factors have such effects on animals lower in the 
scale than human beings, may they not, also, have 
similar effects on man ? 

Want of food may benefit a race if it stimulates to 
greater exertion and eliminates those who are unfit, but 
where the want of food is persistent and great and 
cannot be overcome by greater exertion, the race 
tends to deterioriate ; sometimes the more active 
and energetic members migrate to more favourable 
regions, leaving a residue of a lower grade of energy 
and intelligence behind ; sometimes it is the lack of 
nutrition of the body and mind that leads to the de- 
terioration or even extinction of the race. As to the 
effect of disease, the results will vary. If the disease 

205 



The Political Importance of Malaria 

is short in duration, though severe, and no harmful 
sequelae are left behind, the effect may be, on the 
whole, beneficial, for by the disease the weakly will 
be eliminated and the resistance of the race to the 
disease will be increased. Doubtless in the past 
good has been done by disease, for by it a sifting of 
the strong from the weak has taken place. The 
result, however, is very different if the disease does 
not kill but leaves behind it permanent sequelae, which 
weaken and disable those who have suffered from it, 
and the more intensely the disease attacks a com- 
munity, and especially if it be endemic, the greater 
the harmful effects. In many of these cases racial 
immunity is not established, at all events not within 
thousands of years, so that the race reaps no benefit 
from the disease ; and not only is the race no better, 
it may be far worse. For if all, or even a large 
percentage, of the younger inhabitants of a country 
suffer from a disease which leaves them feeble both 
mentally and bodily, the race will, without doubt, 
deteriorate. 

Major Ross tells us that he has seen whole villages 
destroyed by the parasite of Kala-azar. Until com- 
paratively recently the population of most European 
countries increased very slowly. Some of the enor- 
mous loss of life that this slowness of increase must 
mean was due to war, some was due to famine, but 
by far the greatest share of it must be put to disease. 
Yet unless the disease is one leaving long-lasting 
weakness behind it, the disease may do no permanent 
harm to the people as a whole ; but if it leaves 
behind permanent impairment of mind or body, 
especially if the disease be endemic, its effects on 
the people may last for ages. 

206 



The Political Importance of Malaria 

To any one acquainted with these facts it must 
appear almost self-evident that disease must exert an 
enormous influence on the course of nations, and that 
this influence must have been frequently of greater 
importance than wars or rulers in shaping the destinies 
of peoples. The historian has indeed given credit to 
disease when it has intervened in the course of a 
military expedition, and he has recognised that an 
epidemic among the troops of an army may have 
been the turning-point of a campaign. The Walcheren 
expedition was well conceived, and it owed its utter 
failure almost entirely to the disease which assailed 
it. Had it succeeded in destroying Napoleon's great 
dockyard on the Scheldt it would have had a very 
wide influence on the course of the war. 

Yet more ; the supremacy of a nation strong, wise, 
and healthy may be destroyed by the appearance of 
an endemic disease which saps the life-blood of the 
people, and there is much foundation for the assertion 
that the downfall of Greece was really due, not so 
much to the superiority of its enemies as to the intro- 
duction of malaria into the country. At the present 
time Greece is extremely malarious. Major Ross 
examined many of the inhabitants in the Copaic 
plain, which has replaced the lake drained in 1893, 
and he estimated that quite half of the children were 
infected with malaria, even in June, before the annual 
malaria season had commenced, and this district of 
Greece is not alone in being intensely malarious. It 
has been estimated that in the year 1905, out of a 
population of about two and a half millions nearly a 
million people in Greece were attacked with malaria, 
and nearly six thousand died. It is clear, then, that 
though some parts of Greece are comparatively 

207 



The Political Importance of Malaria 

healthy, the country as a whole is extremely malarious. 
The question then arises whether it has become in- 
fected with the disease within historic times. It is a 
little difficult to imagine that the Greeks in the height 
of their intellectual supremacy could have been a 
people saturated with malaria. Can it be that a 
nation degraded physically and mentally by malaria 
should be capable of creating the masterpieces of the 
Golden Age of Greece ? If, then, we have to confess 
that it is unlikely that the Greeks in their prime were 
malarious, we have to solve the question : When was 
malaria introduced, and is its introduction into Greece 
to be held responsible for the degradation of its 
people ? 

Mr. W. H. S. Jones has studied this matter from 
the historical side, and he has set himself to solve the 
problem of the date of the introduction of malaria 
into Greece. He has made an elaborate investigation 
into the references by classical writers to diseases 
which may reasonably be considered to have been 
manifestations of malaria. It is quite certain that 
malaria existed in ancient Greece. The references 
to it are numerous, and so clear that no doubt can be 
felt on this point. From the year 400 B.C. there is a 
large amount of evidence that in Greece the disease 
was widely prevalent. When the question of the date 
of the introduction of malaria is considered, it is 
fairly clear that there is no reference to any disease 
which can be malaria before the middle of the fifth 
century B.C. 

It cannot be proved that malaria did not exist in 
some parts of Greece even earlier than this, but it 
seems fairly certain that it was absent from Attica. 
If, then, malaria was introduced, whence did it come ? 

208 



The Political Importance of Malaria 

Mr. Jones suggests that as its appearance seems to 
coincide with the Greek expedition to Egypt in 456 
B.C., that may have been the channel through which 
the disease entered Greece, the returning soldiers 
bringing the disease with them. The fact that in 
ancient Greece malaria certainly attacked adults is 
very suggestive that the infection of the country was 
recent. 

If these suppositions are correct, did the introduc- 
tion of malaria have any effect upon the Greek 
character ? There appears to be reason for thinking 
that the Greeks had noticed that malaria tended to 
make patients neurotic, and it is at least possible 
that the gradual change which certainly did take 
place in the Greek character by the end of the fourth 
century B.C. was due to the gradual effect on the 
whole people of endemic malaria. At all events, 
we are justified in thinking that the gradual change 
in the Greek character from the beginning of the 
fourth century was one which would certainly have 
been aided by, and was in all probability caused, 
partly at least, by malaria. 

Another point is worthy of attention. When malaria 
appears to have become prevalent in Greece, large 
numbers of Africans and Asiatics were being poured 
into the country as slaves, and as many of these 
were already immune to malaria, they would be more 
likely to survive, while the native Greeks would gradu- 
ally tend to be eliminated. Thus the disease would 
bring about a change of population which in itself 
must have had a marked effect on national character. 

In discussing the question of the introduction of 
malaria into Italy we have fewer facts on which to 
depend than we have in the case of Greece. The 

209 O 



The Political Importance of Malaria 

earliest Roman physician, Celsus, did not write till 
the first century A.D., and we are quite sure that 
malaria existed in Italy long before that. On the 
whole Italy is, for the most part, not so well adapted 
to the growth of the mosquito as is Greece. 

From 50 B.C. malaria was certainly common in 
many parts of Italy and even in Rome itself, and it 
is possible that its prevalence in Rome was due to 
the fact that, in all the larger houses, in the atrium 
or main room there was a hole in the centre of the 
roof which let in light and also admitted rain into 
a small cistern (the impluvium) in the middle of the 
room, and thus each Roman house possessed a pool 
of stagnant water extremely suitable for a breeding 
site for the mosquito. 

There is some evidence that malaria existed in Italy 
for at least a century before this, but it is fairly 
certain that many parts which are now extremely 
malarious were not always so. No part of Italy is 
more infested with malaria than is the Campagna, 
and yet, from the accounts we possess of its popula- 
tion, it must have been healthy until the beginning 
of the second century B.C. 

What was the effect of malaria on the Roman 
character ? North, in his work on Roman fever, has 
said, "The effect of the disease on the people is to 
unfit them for labour, to cause loss of time, loss of 
money, and generally to diminish their producing 
powers, whilst at the same time the race, if left to 
itself, tends towards moral and physical degradation ; " 
and again — " Malaria is perhaps the most incapacitat- 
ing disease to which man is liable." 

It is certain that at least from the second century 
B.C. malaria was endemic in Rome, and a careful 

210 



The Political Importance of Malaria 

study of history will show that there was a definite 
degradation in the national character in spite of 
the constant introduction of fresh blood from the 
healthier races. The extravagant cruelty and the 
absence of soberness and self-control seen in the 
Roman society of the first century A.D. may well 
be explicable as the result of malaria. Even in the 
present day the brutalities committed by some white 
men in tropical countries are in part due to the 
baleful influence of malaria, and that a similar ex- 
planation is applicable to Rome is extremely probable. 

Although it cannot be maintained that the degrada- 
tion of Greece and Rome was due entirely to malaria, 
yet sufficient has been said to show that in the 
appreciation of the causes of the degradation which 
certainly did exist, sufficient attention has not been 
paid to the influence of endemic diseases ; and the 
study of this subject has also a lesson for us at the 
present day; for it must be appreciated that the 
occurrence of diseases like influenza, which attacks 
many more subjects than it kills, and leaves many 
of them permanently weakened in mind and body, 
cannot fail to exert a very pernicious influence on the 
national character. 

Many of the older physicians who saw the influenza 
epidemics at the end of the eighteenth and the beginning 
of the nineteenth centuries maintained that the consti- 
tution of the inhabitants of this country had changed ; 
for it was no longer possible to treat patients with 
the energetic and drastic methods of treatment which 
had been adopted earlier. It is always difficult to be 
sure of the truth in matters such as this, but there 
is much evidence in support of the idea that some- 
thing had indeed weakened the physical endurance 

211 



The Political Importance of Malaria 

of the people of this country in the early years of 
the nineteenth century, and those who know the 
weakening effect both on mind and body of an attack 
of influenza will be the first to acknowledge that, 
should influenza become permanently endemic in the 
country, it may have far-reaching effects on its in- 
habitants. Influenza causes an irritability of temper, 
a peevishness of disposition, a persistent discontent, 
which, if rendered long-lasting by frequent attacks, 
must exert a most pernicious influence on the mental 
condition of the patient. 

The strain on the nervous system exerted by in- 
fluenza cannot be denied, and whether the disease 
will pass away for many years, as it did from 1850 to 
1889, or whether it will become really endemic, may 
have most important influences on the British char- 
acter and the destinies of this country. 

That malarial disease may change the whole aspect 
of a country is well shown by what has happened in 
Mauritius. Before 1866 Mauritius was an ideal health- 
resort, and many from India used to land there to 
recover; but in 1866 malaria was introduced, and 
in the following year it spread through the whole 
island, destroyed some 30,000 people, and caused a 
great strain on the finances of the island. 



212 



CHAPTER XXI 

THE ROLE OF INSECTS IN THE 
PRODUCTION OF DISEASE 

One of the most striking advances in our knowledge 
of the mode of causation of disease is our recognition 
of the important part which many insects take in 
giving rise to various maladies. As might have been 
expected, the insects are more important in this con- 
nection in the tropics than in the cooler portions of 
the globe, for the hot climate favours the multiplica- 
tion and the rapid development of insects, so that 
they abound to an extent which is hardly realisable 
by those who are unacquainted with hot countries. 
It must be acknowledged that insects are not wholly 
harmful to man. We know that the fertilisation of 
many plants can only be accomplished if certain 
definite insects are present which can carry the pollen 
from one plant to another, and that if an attempt is 
made to grow these plants in a district where those 
special insects are not to be found, the plants, though 
they may grow in great luxuriance, can never set 
their seeds. 

Great though may be the benefits which can be 
derived from insects in this matter of the fertilisation 
of plants, grave doubts may be felt whether, on the 
whole, we do not suffer more harm by their influence 
in producing disease then we derive good from their 
presence. 

213 



The Role of Insects in Disease 

It is hardly necessary to say that the insects which 
help us by assisting in the fertilisation of plants are 
not the same insects which give rise to disease. 

Human beings are not the only sufferers from 
insects. Some of the most troublesome affections 
attacking lower animals are caused through the agency 
of insects. More than a dozen diseases affecting the 
human body can with certainty be ascribed to the 
agency of insects ; and at least the same number of 
diseases affecting the lower animals must be set down 
to a similar cause. 

There are three ways in which insects may prove 
harmful. In the first place some insects are true 
parasites. They exist on or in the skin, or they 
even burrow down into the deeper tissues ; and these 
diseases are of no small importance. As an example 
may be mentioned the itch insect which causes scabies. 
I do not, however, propose to say more about them. 

In the second group of diseases associated with 
insects we may put those diseases in which the insect 
acts merely as the mechanical transporter of an in- 
fective agent. Thus, flies may settle on material con- 
taminated with the germ of typhoid fever ; later, 
they may stop to feed on milk, bread, or some other 
form of food, and their feet, which have become 
contaminated with the typhoid germs, will deposit 
this germ on the food they touch. That this method 
of transmission of disease really does occur has been 
shown by experiment. A fly has been allowed to 
walk on some material containing infective germs, 
and then it has been made to tread on the surface of 
a glass plate covered with a thin film of a material 
suitable for the growth of germs. This plate has 
been kept at a suitable temperature in an incu- 

214 



The Role of Insects in Disease 

bator for the development of the germs, and then, 
at every spot where the fly's feet have trod, there has 
developed a minute group of the infective germs, and 
these groups soon grow large enough to become 
visible to the naked eye. 

It is probable that a large portion of the typhoid 
fever, which slew so many thousands in the South 
African War, was caused by the contamination of the 
food from the swarms of flies which infested the 
British camps. 

Typhoid fever is for the most part produced by the 
drinking of contaminated water or milk, yet we are 
now certain that in special circumstances contami- 
nation of food by flies may be of at least equal import- 
ance. 

The common house-fly assumes a position of greater 
importance in our eyes than heretofore because of 
this power of being the means of transmitting disease, 
and it is not improbable that many other affections 
are conveyed in a similar manner by the common 
house-fly. It is therefore a matter of importance that 
means should be taken to prevent the breeding of 
flies, and the most simple method by w r hich this may 
be done is by taking care that suitable breeding-places 
are not allowed to exist. 

Flies will breed in any heap of decomposing organic 
material, in dust-bins and manure heaps, in fact in 
any heap of rubbish, and therefore precautions should 
be taken to prevent the existence of such heaps longer 
than is necessary. As much as possible they should 
be removed far away from dwellings, or they should 
be covered with a few inches of earth or sprinkled 
with some antiseptic solution. If these precautions 
be taken, the number of house-flies will be noticeably 

215 



The Role of Insects in Disease 

diminished, and the result will add not only to the 
comfort but also definitely to the health and safety of 
the dwellers in the house. 

There is yet a third way in which disease may be 
introduced by the agency of insects, and that is, in- 
sects may act as the " intermediate hosts " of germs 
which can infect the human body. This will require 
a little explanation. 

Many forms of animals, especially parasitic animals, 
exhibit what is called an alternation of generations : 
thus, for instance, the ordinary tape-worm which in- 
habits the human body has two forms of existence. In 
one it exists as a minute worm-like body in the 
muscles of the pig, and when the pork is examined it is 
seen to be speckled all over with little spots, and in 
this condition it is called popularly " measled " pork. 
In this form the worm is so small that it can hardly 
be seen with the naked eye. The white speckle, which 
is seen, is the worm surrounded by a capsule. When 
this pork is eaten by men or dogs, either uncooked or 
cooked insufficiently to kill the parasite, each small 
worm develops in the intestine of its host into a tape- 
worm, which as long as it remains alive continues to 
form daily many hundreds of eggs. These eggs are 
thrown off, and in time become swallowed by a pig, and 
the egg then develops into a minute worm, which passes 
from the stomach of the pig into the muscles, where it 
lies dormant until that pork is eaten by men or dogs. 
Thus, this form of tape-worm has two phases of life, 
one of which is passed through in the pig and the 
other in the alimentary canal of the man or the dog. 

I have described the life history of one of the most 
common forms of tape-worm in order that the reader 
may understand what is mean by an " alternation of 

216 



The Role of Insects in Disease 

generations." Many parasites have in this way two 
existences, one of which is passed in one animal and 
the other in another animal. In each stage the para- 
site inhabits that animal which is most suited for it, 
and it cannot pass through that stage in any other 
animal. Thus the life history of the tape-worm will 
help the reader to comprehend the life history of the 
germs of malaria and of the parasitic causes of several 
other very serious diseases. 

All the insects belonging to this class live by suck- 
ing blood. The insect pierces with its proboscis the 
skin of a man or other animal on which it feeds. The 
proboscis is hollow, and the insect sucks up and 
swallows the blood and lives on it. In some cases the 
insect cannot live in any other way. If the individual 
who has been " bitten " by the insect is healthy, no 
special result follows ; but if, on the other hand, he is 
suffering from malaria, his blood will contain a number 
of the parasites which cause that disease, and when 
the insect swallows some of the blood, it will swallow 
also some of these parasites. When the blood enters 
the stomach of the insect, it undergoes digestion, but 
the parasites are capable of withstanding the action of 
the digestive juices of the insect. They make their 
way through the stomach wall and reach the muscles 
and tissues of the insect. Here they pass through 
certain changes, which differ according to the nature 
of the parasite ; they grow and develop, and ultimately 
make their way into the proboscis of the insect, and 
then, when that insect pierces the skin of another 
person who is healthy, some of the germs from its 
proboscis are introduced into the blood of the healthy 
man, and thus he becomes infected by the parasites. 
So that in this case also, as in the case of the tape- 

217 



The Role of Insects in Disease 

worm, two hosts are necessary for the development 
of the germ. One state of the existence is passed in 
the blood of the human body and one within the 
body of an insect. In order that the reader may under- 
stand fully the life history of these parasites and their 
relation to disease I will describe the case of malaria. 

Malaria is always spread by the agency of certain 
mosquitoes. 

Mosquitoes are small dipterous insects, that is to 
say, they have two wings, and they belong to the 
class Culicidae. Several hundreds of varieties of 
mosquitoes are known, but fortunately only compara- 
tively few of them are capable of assisting in the 
spread of disease. The mosquito cannot develop 
where there is no water, and this is a point of great 
importance in the problem of the prevention of 
malaria. The eggs must be laid by the mosquito on 
water, and unless water is present they cannot hatch, 
therefore mosquitoes cannot exist in large numbers 
in any locality where there is not much stagnant 
water. The water may be in the form of pools or 
swamps, or it may be in rain-water barrels or in 
tanks, and different kinds of mosquitoes differ in their 
requirements. Some only lay their eggs in very 
small pools, or in the water collected in an old meat- 
can ; others require larger pieces of water, but in all 
cases the water must be stagnant. Not only is it 
necessary that there should be water for the laying of 
the eggs of the mosquito, but water is also necessary 
for their development. Two of the stages of the 
insect are free swimming forms, and therefore water 
is essential to enable the insect to pass through those 
stages. 

The eggs of mosquitoes are laid differently accord- 

218 




Larva of Mosqutto 

With a "syphon tube" through which it breathes. 




Mosquito Larvae (Anopheles) 

Resting and breathing at the surface of the water. 



The Role of Insects in Disease 

ing to the species. The special mosquito which causes 
malaria belongs to the family of Anophelinae, and 
these always lay their eggs singly. The Culicinae, 
which are much more widely spread, lay them in 
masses, and they are sealed together with an adhesive 
material so as to form a boat-shaped mass, which can 
float upon the surface of the water. It cannot sink, 
but every breeze blows it along. Some of these boat- 
shaped masses may contain as many as four hundred 
eggs. Even when the eggs are laid singly, each is 
so shaped that it will float, and for this purpose at 
each end of the egg is a hollow cavity, which keeps 
the egg f like a lifeboat, from sinking or even from 
upsetting. 

When the weather is sufficiently warm, the egg 
hatches in two or three days, and then the u larva," 
which is the next stage of the insect, comes out and 
swims about, feeding on the minute organisms in the 
water. All the mosquito larvae breathe air, but the 
breathing apparatus is arranged in two different ways 
according to the species. In some there is a special 
little tube, called a syphon tube, which is held so that 
its upper end is just above the surface of the water. 
The other kind of larva, which has no syphon tube, 
has to lie close to the surface of the water, so that 
a little hole in its body may just touch the surface, 
and through that hole the air passes into the interior 
of the body. The fact that the larvae of the mos- 
quitoes breathe on the surface of the water is of 
importance, for if some paraffin is poured upon the 
water, it is clear that the larvae will not be able to 
breathe and will be suffocated, and this method is 
of some value in killing mosquitoes. After the larva 
has existed for some time it develops into the next 

219 



The Role of Insects in Disease 

stage of the insect, and is called a " nymph " or 
" pupa." During this stage no food is taken, though 
the pupa has to breathe, and this is done through a 
pair of syphon tubes which rest a little above the 
surface of the water. During the two days which 
are occupied by the nymph stage, changes of structure 
are going on in the interior of the body of the animal. 
When the time has come, the mosquito bursts the 
skin which covers it and emerges in the form of the 
fully developed insect, or mosquito. For a few hours 
the insect rests upon the empty case, while its wings 
are drying as it floats about on the surface of the 
water, and at length it flies away. 

All these changes can be seen in England as well 
as in tropical climates, for most of the " gnats " in 
this country are really mosquitoes in everything but 
name. 

As to the structure of the mosquito it will not 
be necessary to say much, but the proboscis deserves 
a description. It consists of many parts. The lip 
forms a sheath, which surrounds the six "stylets" 
or piercing organs, which are very fine, sharp needles, 
and there is a very fine tube, the " hypopharynx," 
through which the saliva of the insect is carried into 
the wound that has been made by the stylets. 

The habits of the mosquito are of great importance, 
as by a knowledge of the customs of the insect it 
is more easy to avoid its attacks and to destroy it. 
As the habits of different species of mosquito differ, 
I will describe mainly the habits of the Anopheles, 
which is the agent in the spread of malaria. 

The mosquitoes do not like the light, and therefore 
they hide during the day in any convenient dark 
spot, but as soon as it begins to get dark, they come 

220 




C* J) 

o ™ 
2 •- 

$3 
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C- 1 * 



The Role of Insects in Disease 

out from their hiding-places and begin to search 
for their food. Some mosquitoes prefer to live away 
from dwelling-houses, and only attack those who 
come into the neighbourhood of their swamps, but 
others may be called domesticated, for they like to 
dwell in houses, hiding in the folds of the clothes, 
or among the rafters. When night comes the mos- 
quito leaves its hiding-place and hunts for a human 
being on whom it may prey, and as it flies about 
it makes a very striking buzzing sound. As soon 
as the insect comes to rest on the skin, it pierces the 
skin and feeds upon the blood. 

It is important to bear in mind that it is only 
the female mosquito which feeds on blood, for the 
diet of the male insect in confined to the juices of 
succulent fruits such as the banana. A mosquito 
does not live long, its average length of life being 
about two months. 

The Malaria Parasite 

There are several varieties of parasite which cause 
the several kinds of malaria, but it will be unneces- 
sary to describe more than one, for they are all so 
very much alike. 

It belongs to the lowest form of animals, for it 
is quite certain that it is an animal, and not a bac- 
terium. If is called the Plasmodium malaria. In 
the course of its life it undergoes several changes of 
form, and this will be most easily understood by an 
account of the life of the germ at its start in the 
blood of a healthy man who has just been bitten. 
When a mosquito infected with the Plasmodium 
" bites" a man hitherto unaffected with the disease, 

221 






The Role of Insects in Disease 

the stylets pierce the skin, and the parasite passes 
along the minute tube called the hypopharynx with 
the saliva, and so it reaches the blood of the person 
bitten. At this stage it is in the form of a minute 
spore, and is called a " sporozoite." As soon as the 
sporozoite reaches the blood it pierces the wall of 
a red corpuscle and makes its way into the interior 
of it. The parasite then begins to grow at the ex- 
pense of the corpuscle in which it is. When the 
parasite has destroyed the whole of the red corpuscle, 
it divides into a very large number of parts, called 
metazoites, which escape from the destroyed red cor- 
puscle ; then each of the smaller parasites enters a 
red corpuscle and the process of destruction of the 
corpuscle is repeated. In this way many thousands 
of the red corpuscles are destroyed. At the same 
time the parasites are giving rise to toxins, and in 
this way the fever is produced, while the destruction 
of the corpuscles leads to the anaemia. It has been 
calculated that two hundred and fifty million para- 
sites may be present in the body during an attack 
of fever. 

If a mosquito only recently emerged from the pupa 
stage comes and attacks a man who is suffering from 
malaria, and drinks some of his blood, it is clear 
that with the blood there will pass into the stomach 
of the insect a number of the malarial parasites. In 
the mosquito's stomach the blood undergoes diges- 
tion, but the germ can resist the digestive juices of 
the mosquito, and it makes its way through the wall 
of the stomach into the tissues of the mosquito, where 
it passes through several changes and ultimately 
divides into very many minute bodies called sporozo- 
ites, and these make their way into the salivary glands 

222 



The Role of Insects in Disease 

of the mosquito, so as to be ready to be injected 
with the saliva of the insect into the next person 
bitten. 

Thus the cycle of the life history of the Plasmodium 
malaria is complete, and we have returned to the 
point from which we started. The outbursts of fever 
correspond to the destruction of the red corpuscles 
and the sudden discharge of the metazoites and toxins 
into the blood stream. 



223 




CHAPTER XXII 

THE R6LE OF INSECTS IN THE PRODUC- 
TION OF DISEASE (continued) 

Yellow Fever 

Yellow fever is an acute disease confined to hot 
climates, and especially associated with Central 
America. It was probably endemic there long before 
it was ever heard of, but it was not until the middle 
of the seventeenth century that its appearance was 
first recorded. Its distribution is almost confined 
to the sea-coast and the districts close to the sea. 
Occasionally cases are introduced into temperate 
climates, but they always fail to spread, and more 
than a century ago it was recognised that it was not 
infectious. Jamaica at one time was much infested 
with the disease, but it was found that it was possible 
to escape the fever by removing to the hilly districts 
during the hot season, and since that has been done, 
the disease has almost disappeared, for the native 
negroes who remain at the sea-coast are immune, 
through having passed through an attack. The mode 
of transmission of the disease has been a matter of 
dispute for very many years ; and it was not until 
1901 that proof was obtained that the bite of a 
mosquito was an essential element in the transmission 
of yellow fever. This was shown by a long series 
of experiments, by which on the one hand it was 

224 



The Role of Insects in Disease 

found that those who were bitten by a certain mos- 
quito which had previously bitten a man suffering 
from yellow fever, contracted the disease, while on 
the other hand those who had been exposed to similar 
conditions, except that they had not been bitten by 
such mosquitoes, did not surfer from the disease. 
Unfortunately Lazear, who was experimenting on the 
subject, and was one of the first to be bitten know- 
ingly by infected mosquitoes, died a few days later. 

The mosquito responsible for the spread of yellow 
fever is named Stegomyia fasciata y and it has been 
shown that it is harmless for twelve days after be- 
coming infected, so that it is certain that development 
of the organism is going on in the body of the 
Stegomyia. 

Yellow fever differs greatly from malaria in one 
very important point. One attack of malaria does 
not immunise the patient against future attacks, but 
he can recover from one attack of yellow fever com- 
pletely, and for ever after he is absolutely immune 
against any further attack. The mortality is very 
high. 

Preventive measures based on the fact that the 
disease is only transmitted by the Stegomyia have 
proved wonderfully successful. We have no certain 
knowledge of the germ of yellow fever. 

Elephantiasis 

In many tropical countries there is a disease called 
elephantiasis ; it is so named from the great enlarge- 
ment of the limbs which occurs, the legs being chiefly 
affected. Sometimes the legs are so much enlarged 
that the patient is hardly able to move about. The 

225 p 




The Role of Insects in Disease 

disease is common in the islands of the East Indian 
Archipelago, but it is found also in the West Indies 
and in some parts of South America. 

The cause has long been known to be the blocking 
of the lymphatic vessels by a long, very thin worm 
called Filaria brucei, which lives in the lymphatic 
vessels, while the embryos of the worm live in the 
blood, where they can be found if looked for. Every 
person who has these embryos in his blood does not 
necessarily suffer from elephantiasis, for in those 
countries where the filaria occurs, very many people 
are found to possess the worm and yet show no sign 
of the disease. The number of filariae in the body 
may be very numerous, and it has been estimated 
that there may be as many as forty million embryos 
present and yet no signs of disease appear unless the 
lymphatic vessels become blocked. Sir Patrick 
Manson found that the embryos appear in the blood 
and then disappear ; and by careful watching he 
found that the filarial embryos begin to appear 
towards evening, increase in numbers during the 
night, and decrease in the morning. He also dis- 
covered a very curious thing. If the patient goes 
to bed during the day, and keeps about at night, the 
filariae also change their habits and appear during the 
day and disappear at night. The object of this 
periodicity has not been ascertained, but it is possibly 
an adaptation of the habits of the filaria to the habits 
of the mosquito. For it has been found that the 
disease is caused by the bite of a mosquito ; probably 
several forms of mosquito can serve as intermediaries, 
but the commonest form is a Culex. The mosquito 
bites a person suffering from filariae and then the 
filaria undergoes in the body of the mosquito changes 

226 




Foot of House-fly 

Showing claws and hairs ; these fine hairs have a sticky secretion, 
to which bacteria adhere, and are carried to food on which the fly 
alights to feed. 




Mosquito of Yellow Fever (Stegomyia) 

The small figure shows its real size. 



The Role of Insects in Disease 

analogous to those which the plasmodium passes 
through in the Anophelinae, developing within the 
muscles of the insect and then making its way to 
the salivary glands, so as to be ready for the time 
that the mosquito makes its next meal. 

Sleeping Sickness 

The disease which is called sleeping sickness was 
until recently confined to the West Coast of Africa, 
but since that time it has spread far and wide in 
Africa. The disease begins with a feverish attack, 
later headache and anaemia appear, and after these 
symptoms have lasted for several months, or even 
years, somnolence comes on and the patient sinks 
into a state of complete unconsciousness and ulti- 
mately dies. The mortality is very high indeed, for 
recovery is very rare. 

The disease is limited to the tropical regions of 
Africa, but in that region within a few years it has 
done a great deal of harm, destroying an immense 
number of people, and Europeans seem to be as 
liable to it as the natives. 

In 190 1 Forde of Gambia found that the disease 
was due to a special organism existing in the blood. 
This is a minute animal very low in the scale ; in fact, 
it belongs to the same great class as the plasmodium, 
for it is a protozoan. It has been named Trypano- 
soma gambinense, and the disease is sometimes called 
trypanosomiasis. The germ is a long wormlike 
body, pointed at each end, and along the side of the 
animal is an undulating membrane, which ends 
anteriorly in a whiplike process called a flagellum, 
which, by means of wavy movements, has the power 

227 








The Role of Insects in Disease 

of making the Trypanosoma move about in the blood 
among the corpuscles. 

When it had been decided that the Trypanosoma 
was the cause of the disease sleeping sickness, it 
remained to be settled how it gained entrance to the 
body of its victims. It has been definitely proved 
that the micro-organism is inoculated into the human 
body through the bite of the fly called the tsetse fly, 
the Glossina palpalis. There are many varieties of 
tsetse flies, and one of them is the means of convey- 
ing to horses the organism which causes tsetse-fly 
disease, which has caused an immense loss in horses 
and cattle in many parts of Africa. That disease is 
also due to a Trypanosoma. 

The tsetse flies do not seem to be able to exist far 
from water, and this limits, to some extent, the areas 
in which the disease can spread. Koch believes that 
the flies infest crocodiles and that is why they live 
near water. When a tsetse fly has bitten a person 
suffering from sleeping sickness, it is able immediately 
to infect a healthy man by biting him. It does not 
appear that there is any need for a prolonged cycle of 
changes in the body of the fly, though such a cycle 
of changes does occur. 

The Plague 

One of the oldest epidemic diseases is the plague, 
and it has on many occasions visited the British Isles ; 
the best known visitation being that which occurred 
in 1665, the year before the Great Fire of London. 
At present it is mainly confined to Asia, though it is 
showing a tendency to travel farther afield. In 1894 
Kitasato discovered the microbe which gives rise to 

228 




Armed against the Plague in China 



The doctor on the right is wearing the full working kit of linen, which can be boiled 
and disinfected easily, and he is breathing through a pad of lint soaked in carbolic 
acid. 



The Role of Insects in Disease 

the disease. It is a bacterium, and has been named 
Bacillus pestis. 

It has long been known that when the plague has 
prevailed in any town or district, there has at the same 
time been a great mortality amongst the rats, and now 
we know that rats and some other animals can suffer 
from the plague. It seemed therefore probable that the 
rats brought the disease to a district, or at least assisted 
in spreading it. After much research it has been 
found that the agent responsible for spreading the 
disease to man is a form of flea. The flea that 
usually attacks human beings is called Pulex irritans, 
but the flea which is the agent in spreading the plague 
is a variety called Pulex cheopis. When a rat which 
is suffering from the plague is bitten by a flea of the 
kind called Pulex cheopis, which is the form that 
affects the black rat, the flea, with the blood which it 
sucks up, will take into itself some of the plague 
germs. So long as that rat lives, its fleas have very 
little tendency to leave it, but as soon as the rat dies, 
its fleas forsake it at once and seek another host ; this 
may be another rat, or, if no other rat is available, they 
will attack a human being ; but whether they attack a 
rat or a man, the one bitten will suffer from plague. 

The Bacillus pestis has been shown to exist in a 
flea that has bitten a rat suffering from the plague. 
If a healthy rat be put into a cage with a rat suffering 
from the disease, it will not contract the disease if 
care has been taken to free both rats from fleas. If, 
however, the affected rat is allowed to retain its fleas 
when it is shut up with a healthy rat, the disease will 
be transmitted to the healthy rat as soon as the fleas 
pass from the affected rat to the healthy rat, and 
that will be probably as soon as the sick rat dies. 

229 



The Role of Insects in Disease 

When the Bacillus pestis is in the stomach of the 
flea it is able to grow and increase in numbers, but it 
does not undergo any other change. 

There is another point that helps to spread the 
plague. When any rats are taken ill, their natural 
tendency appears to be to leave the neighbourhood, 
and thus the affected rats take the disease with them 
to places previously healthy. 

The plague appeared certainly in Egypt nearly two 
thousand years ago, and it is probable that it had 
visited the country long before that. Surprise has 
often been expressed that in ancient Egypt cats should 
have been an object of worship. The suggestion has 
been made that it had been noticed that the plague 
was not so likely to attack houses where cats were 
numerous, and therefore the cats had been looked 
upon as supernatural and had been considered 
worthy of worship. Whether there is any truth in 
the suggestion or not cannot, of course, be decided, 
but it is at least not very improbable. It is at all 
events certain that rats are responsible for introducing 
the plague into most countries. Therefore attempts 
should be made to exterminate rats completely, or, 
if this is not practically possible, at least to reduce 
their numbers greatly. A determined effort should 
be made, and it must be a general effort, extending 
over the whole of the country ; for if it is limited to 
a very few districts, the rats will leave those places 
where they are being troubled and will seek for some 
part of the country where they can be at peace. 

When a ship carries wheat or any form of grain, 
it has always a large number of rats on board, and if 
that ship should come from a port where there have 
been cases of plague there is a very great probability 

230 



The Role of Insects in Disease 

that the rats on board will be affected with the 
disease. Even if the port of origin of the ship 
should be plague-free, if the vessel should in the 
course of a voyage touch at a port where there are 
cases of the plague, there will be a very great risk 
that the disease will be carried by the ship. 

All vessels coming from infected ports should be 
placed in quarantine until the rats and their fleas have 
been examined for the Bacillus pestis. Care has to 
be taken that rats do not escape to land from the 
quarantined vessels, carrying with them the germs of 
the disease. 

There are many other diseases of importance, some 
of them affecting man and some of them affecting the 
lower animals, which are due to insects, but it is 
unnecessary to mention any more instances. Enough 
has been said to show that many insects are to be 
held responsible for spreading many serious maladies, 
and that the best fnethod to prevent any of these 
diseases, is to get rid of the insects which are its 
promoters. 



231 



CHAPTER XXIII 
THE FIGHT AGAINST MALARIA 




In preceding chapters I have described with some 
fulness the devastation which has been wrought by 
the prevalence of malarial disease in certain countries. 
I have traced the mode in which the disease arises 
and is transmitted, and I have shown how the very 
existence of the disease is dependent on certain 
physical conditions. 

As soon as our knowledge of the mode of the origin 
of the disease began to be complete, attempts to utilise 
this knowledge for the prevention of malaria were 
made, and in this chapter I give an account of the 
chief methods that have been adopted for this purpose 
and I describe the measure of success which those 
efforts have met with. 

Should it be possible to eradicate malaria and other 
kindred diseases from the tropical regions of the earth, 
a great increase in the area habitable by white men 
would be obtained. Although the tropical heat and 
the intense glare of the tropical sun are not specially 
suited for white races, and though, as I have else- 
where mentioned, the intensity of sunlight may in 
itself prove harmful to those unprovided with a fully 
pigmented skin, yet with a few and comparatively 
simple precautions it is possible for white men to live 
in health and comfort within the tropics, provided 

232 



The Fight against Malaria 

only that malaria and the allied tropical diseases are 
not present. 

The importance, therefore, of making great exertions 
to put an end to the dominion of malaria cannot be 
disputed, and the success which even now has been 
obtained demonstrates clearly the wisdom of this 
effort. Many of the measures which have been 
adopted for the prevention of malaria are almost 
equally applicable to yellow fever and some other 
insect-borne diseases, but in this account I shall speak 
especially of those procedures which experience has 
shown to be of chief value in the prevention of 
malaria. 

In the territories of ancient Rome many great 
drainage works were carried out in districts which are 
now extremely malarious, but it is at least doubtful 
whether this drainage was intended to prevent the 
malaria or to render the land fit for agricultural 
purposes. It is nevertheless a fact that, when the 
drainage was neglected and the canals were allowed 
to silt up, malaria appeared, and even to the present 
day it has prevented the utilisation of extensive 
districts for agriculture. Whatever may be the truth 
in regard to the ancient drainage works, it has for 
centuries been known in Italy that drainage and 
similar measures have a very real control over the 
occurrence of malaria. 

When in our own time the mode of origin of 
malaria had been conclusively traced to the bites of 
mosquitoes, the question arose whether it might be 
possible, by controlling the breeding of the mosquitoes 
specially concerned, to limit the extent of the disease. 
Major Ronald Ross in 1884, while at Bangalore in 
Southern India, noticed that mosquitoes were much 

233 



The Fight against Malaria 

reduced in number in his house, when he took care 
that rain-water was not allowed to remain in tubs 
and pots in the garden. Later, in 1897, Major Ross 
observed that the larvae of the Anophelines, the 
mosquitoes which are connected with malaria, did not 
breed in the tubs and pots where other mosquitoes, 
Culex and Stegomyia, bred, but mostly in pools of 
water on the ground. Thus he perceived the explana- 
tion of the fact that malaria is especially connected 
with pools and marshes. He noticed that the 
Anophelines bred, not in large areas of water such 
as lakes and reservoirs and not in tubs, but gene- 
rally in small, shallow pools, and that, like other 
mosquitoes, they were most prevalent near their 
breeding-places. He endeavoured by writing and 
by practical attempts to carry out the measures 
suggested by these observations. He maintained that 
it might be possible to remove all opportunities for 
breeding of mosquitoes from the towns, even though 
such attempts might be impracticable in a water- 
logged district, and he laid down the rule that it is 
one of the first sanitary duties of all municipalities 
and town councils in warm climates to keep down, 
as much as possible, the numbers of mosquitoes 
within the area placed under their care ; for it is 
certain that, if a municipality can afford to have a 
water supply laid on and a system of sewerage, it can 
surely afford the expenditure of money necessary to 
render it free from malaria and other similar insect- 
borne diseases. 

He went with two others to Freetown, the capital 
of Sierra Leone, on the West Coast of Africa, to 
study the matter on the spot, and to see what could 
be done. Two local mosquitoes, Anophelines, were 

234 



The Fight against Malaria 

identified by him as carriers of malaria, and then 
their habits were studied with the object of working 
out a plan for the reduction of the number of mos- 
quitoes. The main facts connected with the habits 
of the Anophelines were discovered, and the broad 
distinctions between them and the Culicines were 
pointed out. 

The publication of the results of these researches 
gave a great impetus to the work of the prevention 
of malaria. Little was, however, done at Freetown 
beyond appointing a single person for a few months 
to check the mosquitoes. In 1901 Major Ross with 
the help of some friends made an attempt to reduce 
the number of mosquitoes at Freetown, for he had 
become convinced that anti-malarial campaigns had 
better be conducted not only against Anophelines, 
but against all kinds of mosquitoes at once, for by 
that time it had become known that yellow fever 
was conveyed by a mosquito, a Stegomyia. He 
engaged the services of twenty men, and the Governor 
of Sierra Leone added twelve to the number. With 
the help of these, large quantities of mosquito-breed- 
ing rubbish were removed, and many Anopheline 
pools were filled up or drained. This work made a 
great reduction in the number of mosquitoes, but the 
local authorities did not appear to be willing to 
continue the measures of prevention, and the work 
was allowed to lapse. 

In 1902 Major Ross was asked to go to Ismailia 
to advise what should be done to prevent malaria. 
When Lesseps made the Suez Canal, he founded the 
town of Ismailia ; he intended it to be an important 
city, and he placed it on a small salt-water lake, Lake 
Timsah. He placed the headquarters of the Suez 

235 



The Fight against Malaria 

Canal Company there, houses were built overlooking 
the Canal, and public gardens were made. Boating 
was possible, and bathing, free from sharks, and 
shooting could also be had. As the town was in the 
desert and not near any other town, it proved to be 
very healthy, and the Company did all it could to 
make it a perfect city. The water supply of Ismailia 
came by a fresh-water canal, made in 1877, con- 
nected with the Nile. Five years later the canal 
was deepened to allow boats to use it to pass from 
Cairo to Ismailia. The water contained a good deal 
of solid matter, and, as it was used to water the 
gardens and parks, the vegetation grew well. For a 
time all went well, but the water was allowed to run 
to waste, and marshes and ponds formed near and 
even in the town itself. 

Soon after the marshes had formed, mosquitoes 
appeared, and a little later malaria appeared also. In 
the first year, 1877, three hundred cases occurred in 
the months from August to December. By 1891 the 
number had increased to nearly 2500, and attempts 
were made to prevent the disease by partial drainage 
of the marshes, but this was in the days before the 
mosquito theory of malaria had been formed. 

The population of Ismailia had at one time reached 
10,000, but the advent of malaria changed everything. 
There was so much sickness that the work could not 
be done, and trade came to an end. It was re- 
solved to move the offices of the Canal to Port Said, 
and the town diminished in population. 

An attempt to control the disease by the free dis- 
tribution of quinine had been made, but it had not 
proved successful. 

So in 1902, when Major Ross went to Ismailia to 

236 



The Fight against Malaria 

see what could be done to prevent the prevalence of 
the Malaria, he advised that an attempt should be 
made to exterminate the mosquitoes, which were both 
Culicines and Anophelines. The chief places for the 
breeding of the mosquitoes were shallow pools result- 
ing from the irrigation, and there was a cesspool 
under every house. There were no mosquitoes in the 
fresh-water canal, for the water was always flowing, 
but near Ismailia the canal leaked and a marsh had 
formed, and in this marsh larvae of mosquitoes were 
found. The marsh was drained so that it could no 
longer harbour mosquitoes, and all the pools were 
filled. All the irrigation conduits, both great and 
small, were cleared of weeds so that the water was able 
to flow rapidly. The water to each garden was 
allowed to flow only as long as necessary, and then 
the supply was stopped. Every house was visited 
once a week, and petroleum was poured over the sur- 
face of the cesspools. All tubs and other vessels con- 
taining water were regularly emptied, and a fine was 
put on all failures to report collections of water which 
had not been treated. To carry out these measures 
only four officials were employed. 

The results were very wonderful. In 1900 there 
were 2284 cases of malaria. In 1901 there were 1990 
cases. In 1902 the number was 1551. In the next 
year the number had fallen to 214. In 1904 it was 
90, in 1905 there were 37 cases, and since then there 
have been no cases in which the disease had been 
caught in Ismailia. It is true that cases are still oc- 
casionally introduced into the town from villages on 
the fresh-water canal at a distance from Ismailia, but 
the disease never spreads in the town itself, for there 
are no Anophelines there. 

237 






The Fight against Malaria 

The Panama Canal 

The work which has been done in the neighbour- 
hood of the Panama Canal deserves mention. The 
canal measures some forty-two miles from shore to 
shore ; for about two-thirds of this distance the 
country is mountainous and for one-third low and 
swampy. The railway between Panama and Colon 
is about forty-seven miles long, and a population of 
about 80,000 persons lives within half a mile of the 
railway. The whole length is divided into eighteen 
districts, each in charge of an inspector, and each 
inspector has about fifty men under him. The anti- 
malarial work performed there comprised several 
operations, of which the most important was drainage. 
The inspector had to drain and do away with all pools 
within 200 yards of every village, and the most 
effective and economical method appears to be sub- 
soil drainage. 

Secondly, all undergrowths have to be cut down 
within 200 yards of the villages, the grass not being 
allowed to be more than a foot high. This is con- 
sidered of importance because the adult mosquito 
cannot cross a cleared area of 100 yards. The 
application of petroleum is also employed where 
drainage is either impracticable or too costly, as on 
the edge of a swamp. The oil must be thin enough 
to spread readily, but it must not be too thin, or it 
will evaporate too soon. 

The use of "larvicide" is also of importance. On 
the grassy edge of ponds or streams oil will not 
spread, and Anopheline larvae breed there readily. 
In such a place a liquid is used which is poisonous to 
the larvae. The form used consists chiefly of car- 

238 



The Fight against Malaria 

bolic acid and caustic soda. In the Panama district 
quinine is distributed freely ; it is given without 
charge to any one applying at any dispensary, and 
it is placed on all hotel tables and mess tables. There 
are also quinine dispensers who visit the various 
squads of negroes at work and offer every one quinine. 
In one year more than three thousand pounds of 
quinine were employed. Lastly, all Government build- 
ings are screened so as to keep them mosquito-proof. 
The results have been very gratifying, and the 
value of the measures undertaken has been fully 
proved. 

Havana 

The prophylactic measures which were undertaken 
at Havana were mainly directed against those mos- 
quitoes which produce yellow fever, yet, with the 
removal of the yellow fever, malaria has disappeared 
also. 

It will be clear from the preceding account of 
the work that has been done that there are many 
methods which are of value in the prevention of 
malaria. The relative importance of these will vary 
somewhat according to the local conditions. In 
most marshy districts the measure which must be 
considered of the greatest value is drainage, for by 
drainage marshy land can be rendered dry, but the 
extent and therefore the expense of any drainage 
operations must depend greatly on the area to be 
treated. Where possible, covered drains are much 
more effective than surface ditches, for ditches, un- 
less lined with tiles, become easily choked by the rapid 
growth of tropical vegetation, and a sudden heavy 
shower may entirely destroy a ditch. The covered 

239 




The Fight against Malaria 

drain will of course be much more expensive at first, 
but it will rarely require cleaning, while the surface 
drain, though economical in construction, requires 
much more frequent attention. 

All receptacles of water require to be kept covered 
or empty ; flower-pots and water-tubs must not be 
allowed to hold rain-water or must be covered, and 
even hollows in trees that may catch water must 
be filled up. All pools must be filled in, and care 
should be taken that no empty tins are allowed to lie 
about, in which rain-water might accumulate. 

The next most important point is that if there is 
any moist or watery area which cannot be drained 
or cannot be filled in, it must be covered with petro- 
leum. This forms an impervious layer and prevents 
the breathing of the larvae. 

It is desirable that the minimum amount of under- 
growth be left in the neighbourhood of houses, for 
the less the undergrowth the more readily the ground 
dries and the greater difficulty the mosquitoes find 
in reaching houses from swamps at a distance. 

Antiseptics such as carbolic acid can also be used 
where conditions are favourable for the larvae but are 
unsuited for the use of petroleum. 

Individual prophylaxis by the use of mosquito 
curtains must not be despised in the early stage of 
a prophylactic anti-malarial campaign, but it is clear 
that its value will diminish as the other measures prove 
effective. It has been conclusively shown that it is 
possible to sleep in the most malarious parts of the 
Campagna without infection, provided that care is 
taken to surround the house or the beds with mos- 
quito nets. There are, however, certain cases where 
the value of mosquito curtains becomes very great. 

240 



The Fight against Malaria 

When a boat has to pass through a malarious district 
or call at a malarious port, as much of the ship as 
possible should be screened. The use of the mos- 
quito net is very old. 

The use of quinine as a prophylactic must not be 
despised, especially when beginning work in a malari- 
ous country. The use of quinine to stamp out 
malaria was suggested by Koch. This method aims 
at the destruction of the parasites themselves by the 
general administration of quinine to all the infected 
persons in a locality. If this is done the Anophelines, 
however numerous, will be harmless, for there will 
be no parasites by which they can become infected. 
The quinine should either be given away freely or 
sold at a very low price. As to its value in the pre- 
vention of malaria there can be no doubt. 

Many measures have been described for the pre- 
vention of malaria, and the question will arise which 
should be used. The answer is simple. On the 
whole it is best to use them all, but drainage and the 
filling up of ponds and pools are of much greater 
importance than any other measures. In any case, 
however, where only certain of these methods are 
possible, it is far better to employ those methods 
which can be used than to do nothing at all. It may 
be that it will prove impossible absolutely to exter- 
minate mosquitoes ; nevertheless, there will certainly 
be a great reduction in their number, and the extent 
of the disease will be correspondingly diminished. 
It must fully be understood that any one of these 
methods carried out thoroughly and energetically will 
have a very definite effect on the extent of the disease. 

The measures above described will tend to remove 
all mosquitoes from a district, and thus they will 

241 Q 




The Fight against Malaria 

serve, not merely to prevent malaria, but also the 
many other diseases which we know are induced by 
the bites of mosquitoes. In time to come the im- 
portance of the prevention of such diseases will be 
more fully appreciated than at present. It is not un- 
likely that in the future we shall find that there are 
other diseases induced by the bites of insects in addi- 
tion to those we know of already. 



242 



CHAPTER XXIV 

INDUSTRIAL DISEASES 

The progress of civilisation, however beneficial it may 
be to the human race, is not without its disadvantages. 
One of the effects of the spread of civilisation has 
been an increase in the diseases from which mankind 
suffers. Of this increase there are doubtless many 
causes, and not the least important of these is the 
invention of new manufactures and occupations, 
which give rise to new maladies in those who follow 
them. If I were to include all the harmful results 
which may follow trades and industries the recital 
would prove wearisome, and therefore I will confine 
my account to some of the more striking. 

There are only a few of the metals which commonly 
harm those concerned in their working, and the most 
important of these is lead. 

Lead Poisoning 

Poisoning by lead, or plumbism, is by no means 
confined to those who work in lead, for it may affect 
many others. It is a serious affection, and in the 
more acute form of lead poisoning the chief symptom 
is abdominal pain, and to this the name of "painter's 
colic" has been applied. The pain may be very 
severe, but it responds readily to suitable treatment. 
The other important manifestation of lead poisoning 

243 



Industrial Diseases 

is "wrist drop/' that is, paralysis of the muscles at 
the back of the wrist, so that the hand falls and cannot 
be bent upwards. There are, however, other im- 
portant morbid conditions caused by lead, and a fatal 
result is far from rare. 

Most water pipes are composed of lead, and under 
certain conditions the lead in the water attacks the 
metal in the pipe, dissolving some of the lead, so that 
those who drink the water which has been conveyed 
through those pipes are liable to suffer from lead 
poisoning. The lead may also be taken into solution 
by the water while it has been stored in a leaden 
cistern. It is curious that the purer the water is — that 
is, the less mineral matter it contains — the greater the 
tendency it has to act upon lead ; while if it is hard, 
containing much chalk and other mineral matter, the 
action on the lead is comparatively slight. Thus the 
great efforts which have been made to provide cities 
with pure water have led indirectly to harmful results. 
Even ordinary hard water is liable to act on lead 
pipes for a time, but before long the mineral matter 
present in the water combines with the lead to form 
some insoluble salts, which line the pipes, so that 
no more action can be produced. 

In the year 1848 King Louis Philippe was living in 
exile at Claremont ; and some of the members of 
the Orleans royal family and other persons of the 
household became affected with severe attacks of 
colic with some nervous symptoms, which were evi- 
dently the results of lead poisoning. Altogether more 
than a third of the residents of Claremont suffered. 
It was ultimately found that the attacks were due to 
lead in the drinking water ; the lead had been taken 
up by the water from the leaden pipes through which 

244 



Industrial Diseases 

the water was supplied to the household. The quantity 
of lead was large, for each gallon of water contained 
nearly three-quarters of a grain of lead. 

Sometimes lead poisoning is produced from the 
eating of tinned food, the acid juice of the food 
acting upon the solder, which contains a large pro- 
portion of lead. In some enamelled saucepans the 
enamel contains lead in large quantities, and if certain 
acid foods are cooked in these, some of the lead may 
go into solution. Aerated waters also occasionally 
contain lead, and this is sometimes due to the fact that 
they have been made from water already con- 
taminated with lead, but more commonly it is due 
to the fact that the fittings of the syphons contain 
lead. 

Yet another method by which lead can enter the 
system is the use of certain hair-dyes, for many hair- 
dyes contain lead, and even though the lead is merely 
applied externally, symptoms of lead poisoning have in 
certain cases been known. 

Lead mining is a very old industry, for bars of lead 
have been found in Derbyshire bearing a stamp indi- 
cating that they were made during the Roman 
occupation of Britain, but the industry is not advanc- 
ing, as much foreign lead is imported. In this country 
there is very little risk of poisoning in working in lead 
mines, as the ore consists of galena or lead sulphide. 
In Australia, however, at the mines at Broken Hill, 
lead miners are liable to suffer severely, and the 
reason for this is that there the ore is cerusite, which 
is the carbonate of lead, and this is more poisonous 
than the sulphide. 

It is, however, in those who work in lead that lead 
poisoning has become of the greatest importance. 

245 







Industrial Diseases 

Those concerned in the smelting of lead are liable to 
be affected, for the fumes which come from the flue 
of the smelting-shop contain salts of lead which are 
poisonous. The fumes are usually carried into a flue 
a mile or two long, and in this long flue much of the 
lead is deposited, and at intervals these flues have to 
be cleared out, and this is a task which is very liable 
to lead to lead poisoning. 

Those also concerned in the manufacture of white 
lead, which is so widely used for paint, often suffer 
from plumbism. White lead is made as follows : 
On a layer of spent tan are placed many earthenware 
pots containing weak acetic acid, and on the pots are 
placed the sheets of lead. Similar layers of tan, pots, 
and lead are placed over the first until the ceiling is 
reached, and then the door is closed and the " stacks," 
as they are called, are left for about three months. 
The tan ferments and evolves heat, and this evaporates 
the acetic acid, which attacks the lead, and ultimately 
white lead is formed. Later this has to be stripped 
off the unaltered metallic lead, and during this process 
much dust is formed, and this is very poisonous. At 
the present time there is less dust, as by the regula- 
tions the "beds" must be watered by a "rose." In 
the subsequent drying and packing there is risk of 
poisoning, but it is possible to replace much of the 
work by mechanical appliances, and these have been 
adopted to a very large extent. Formerly women 
worked in white lead factories, and plumbism was 
very common. Cases have occurred in which strong 
and healthy young women have died within three 
months from first entering a white lead factory. Dr. 
T. Oliver believes that women are more liable to 
plumbism than men, and that a similar predisposition 

246 



Industrial Diseases 

exists in certain families and in certain individuals. 
At present, women are forbidden by law to engage in 
this industry. 

All who work with lead, such as file cutters, glass 
polishers, and plumbers, may suffer from lead poison- 
ing. 

File cutters employ a block of lead on which the 
file rests while it is being cut with a chisel and a 
hammer. The workrooms are often badly ventilated, 
and the dust, containing fine particles of metallic 
lead, is breathed by the workers. 

Much of the poisoning is also due to eating without 
a previous washing of the hands. It is probable that 
in time file cutting by hand will be replaced by file 
cutting by machinery ; this is a healthy process, and 
no lead is employed in it. 

Glass polishers suffer from lead poisoning because 
putty powder is used, and this contains about 70 
per cent, of oxide of lead. The putty powder is mixed 
with water and applied to a brush which is attached 
to the rim of a rapidly revolving wheel, against which 
the glass to be polished is held. The wheel revolves 
so rapidly that it sprinkles the putty powder in every 
direction, so that the hands and clothes of the work- 
men become soiled with the putty powder. Even 
workmen in the glass polishing shops who are not 
occupied in glass polishing may become affected with 
lead poisoning, and this is owing to the fact that the 
dust of the workshop contains lead and it is inhaled. 
Substitutes for putty powder have been suggested and 
employed ; rouge, which is crude oxide of tin, is a 
decided improvement, and very good results have 
followed the use of metastannic acid. 

Lead poisoning is perhaps most commonly seen 
247 



Industrial Diseases 

in painters, and in this trade it appears to be chiefly 
due to the painter eating with unwashed hands ; for 
if care be taken to remove the paint from the hands 
before each meal, lead poisoning does not occur. 
It can easily be understood that the workmen's hands 
are smeared with particles of paint, and any food, 
such as bread, taken into the hands may become 
contaminated and serve to convey the paint to the 
mouth. 

Type-founding is also a trade in which lead poison- 
ing is possible. The metal used for type consists 
of lead to which is added a small quantity of antimony 
to make the metal harder and a more exact copy 
of the mould. Compositors also, who set up type 
and handle the type for several hours a day, oc- 
casionally suffer from lead poisoning. In Berlin ten 
per cent, of the printers were yearly affected with 
lead colic, but it is much less common in this country. 
Dr. Mortais has reported a tale told to him which 
illustrates well the risk of lead poisoning in printing 
offices. Some printers informed him that for twenty 
years they had tried to keep a cat in the workroom 
but in vain. The cat was always well fed and had 
plenty of milk, and for some time it would seem to 
be in good health, but sooner or later its eyes would 
lose their healthy appearance and its legs would be- 
come paralysed. This happened time after time. 
Lead poisoning would probably also be prevented 
among printers by care being paid to cleansing the 
hands before eating. 

The earliest account which we possess of definite 
lead poisoning was written in 1517 by Francis Citois 
of Poictou. He described an endemic disease existing 
in that province, and even then it was recognised 

248 



Industrial Diseases 

that it was somehow connected with the wine of that 
country. We now know that preparations of lead 
were used to prevent the wine from turning sour. 
There was no intention on the part of the wine- 
makers to adulterate the product, for the practice 
was employed by every wine-grower, and was well 
known to all. 

In Devonshire, in the eighteenth century, a similar 
affection was rife. It was so common, that within 
the five years ending in 1767 two hundred and eighty- 
five cases were admitted into the Devon and Exeter 
Hospital. It was recognised that it was somehow 
connected with cider, and it was noticed that it did 
not occur every year with equal frequency, but it was 
more common when cider was plentiful because of 
a large crop of apples. The subject was investigated 
by Sir George Baker, and he, by a process of clever 
reasoning, worked out the origin of the disease. The 
first step was to show that in other counties, such 
as Hereford, Gloucester, and Worcester, where cider 
was commonly drunk, those who took it did not 
suffer from colic. Then by analysis it was proved 
that Devonshire cider contained lead which was not 
found in cider from other counties, and therefore 
it was probably the cause of the disease. The ques- 
tion then to be solved was, How did the lead get 
into the cider? It was found that there were two 
possible sources. When cider was very plentiful all 
kinds of receptacles were utilised to contain the large 
amount of cider made, and sufficient barrels not being 
obtainable, recourse was had to leaden cisterns ; the 
acid cider acted on the lead, and thus the lead was 
brought into solution, and gave rise to the affection. 
The other possible source of the lead was to be found 

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in the fact that leaden weights were sometimes put 
into the casks to prevent the cider turning sour. 

In the West Indies, also, frequent attacks of colic 
occurred, and it was ultimately discovered that only 
those were affected who drank rum ; and in this case 
the lead made its way into the rum because the stills 
in which the rum was distilled were provided with 
leaden condensers. As soon as it was recognised 
that lead was the cause of the symptoms in these 
cases, the use of leaden condensers was done away 
with and the poisoning ceased. 

The only ways at present in which lead poisoning 
occurs from the use of beverages other than water 
are, first, the employment of leaden shot to cleanse 
bottles, some of the shot being accidentally left 
behind, and the second is through the use of syphons 
in which the contained liquid comes in contact with 
the lead metal fittings. In this case the best pre- 
ventive is the use of fittings made of pure tin. 



250 



CHAPTER XXV 

INDUSTRIAL DISEASES {continued) 

Mercurial Poisoning 

Poisoning amongst workers in mercury is less 
common now than it was at one time, because at 
the present day mercury is much less used for making 
mirrors than formerly, and that was the chief industry 
in which the mercurial poisoning occurred. At the 
present time probably not more than iooo persons in 
Great Britain are exposed to the risk of poisoning by 
mercury. As long ago as 1665 Dr. W. Pope referred 
in the Pliilosophical Transactions to tremors of the 
hands of a worker in cinnabar mines in Italy. Miners 
of mercury ores are liable to suffer, but improved care 
has largely reduced the risk. Formerly, when most 
of the mercury used in Great Britain came from 
Spain, the occupation of quicksilver mining was so 
unhealthy that the work had to be done by convicts, 
and the lack of personal cleanliness in the men, com- 
bined with the natural unhealthiness of the occupa- 
tion, led to such a great mortality that it was recog- 
nised that the sentence of working in the quicksilver 
mines was almost equivalent to a sentence of death. 

Mirrors used to be made with mercury, and though 
the process is now superseded, a description of it 
will be of interest. A sheet of tin-foil was spread out 
on a table of marble or glass, which must be perfectly 
level. A small amount of mercury was spread on to 

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Industrial Diseases 

this, so as to form an amalgam with it, and then a 
larger amount of the mercury was added and a piece 
of plate glass, perfectly smooth, was slid over it. 
Heavy weights were placed upon the face of the 
glass to press out the excess of the mercury, and after 
a few days it was found that the amalgam of tin and 
mercury had adhered to the glass. 

This method has been replaced by the silver 
process, which is carried out as follows. The plate 
of glass is laid in a horizontal position and a solution 
of silver nitrate, to which has been added some 
ammonia, is poured over it. At first a black pre- 
cipitate is formed, but later there is a deposit of 
shining silver. It will be seen that no mercury is used 
in the process. 

Formerly chronic mercurial poisoning was fairly 
common in this country amongst water gilders, who 
used to employ an amalgam of gold and mercury for 
gilding. A layer of the amalgam was spread over the 
surface to be gilded, and then the article was heated 
by a charcoal fire, with the result that the mercury 
was driven off and the gold was left in a very thin 
layer on the surface. 

The vapour of the mercury was very liable to affect 
the workmen engaged in the work. Fortunately the 
process of water-gilding has been almost completely 
replaced by electro-plating, to which no such risks are 
attached, though it is said that some buttons are still 
gilded by the older method ; but even water-gilding 
was not so dangerous an occupation as might be 
imagined, for a case is recorded in which a water- 
gilder was attacked by poisoning for the first time after 
having followed his occupation for seventeen years. 

There are still many industries in which mercurial 

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Industrial Diseases 

poisoning may occur. The metal is used in the 
manufacture of barometers and thermometers. In- 
candescent electric lamps are often exhausted by 
means of a mercurial pump, and that causes risk of 
poisoning, and in electric meters mercury is also 
employed. In paint works, where anti-fouling paints 
are made, and in the workshops of hatters and l furriers, 
mercurial poisoning is also possible. 

When liquid metallic mercury is swallowed in even 
fairly large quantities, poisoning very rarely occurs, 
but mercurial vapour soon produces symptoms of 
poisoning. The main signs of mercurialism are 
pallor, headache, giddiness, and tremors of the tongue 
and limbs. 

The chief ore of mercury is cinnabar or sulphide of 
mercury ; this has to be heated to set free the mercury, 
and among the men engaged in this occupation, more 
than ten per cent, suffered from poisoning in five 
years. In most of the trades dangerous from mer- 
curialism, it is the vapour which does the harm. In 
the processes connected with the making of felt hats, 
a dilute solution of the nitrate of mercury is employed. 
The skin is brushed with the solution, and after drying, 
it is brushed by machinery to loosen the fur, and in 
this way the mercurial salt is scattered about. 

Phosphorus Poisoning 

Poisoning by phosphorus occurring in the course of 
industry is almost confined to the making of matches. 
To understand fully the problem which faces the 
maker of matches it is necessary to know something 
about phosphorus. Phosphorus exists in two very 
different forms, although chemically they are identical. 

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Industrial Diseases 

What is known as white phosphorus is the common 
form, and it is that which; is used in ordinary lucifer 
matches. It can catch fire by simple friction, and at 
ordinary temperatures it is continually giving off 
fumes. It is extremely poisonous. In the making of 
matches a composition is prepared composed of phos- 
phorus, glue, potassium chlorate, and powdered glass. 
It contains usually five per cent, of phosphorus. 
This composition is spread on a heated iron slab, and 
into it the matches tied up in bundles are dipped, and 
then they are laid out to dry. During the whole of 
this process phosphorus fumes are being given off, 
both from the composition and from the drying 
matches. When the matches are dry, they are placed 
in boxes, and the women who do this get some phos- 
phorus on to their hands, which smell strongly of it, 
and if, as not rarely happens, some of the matches 
catch fire, dense clouds of smoke are also given off. 
Thus the workers inhale a great deal of phosphorus 
fumes. 

The other form of phosphorus, or red phosphorus, 
as it is called, was discovered in 1845. It can be 
prepared cheaply from the white variety, merely by 
the action of heat in closed vessels. Its properties 
are very different from those of white phosphorus, 
for it will not catch fire with simple friction. More- 
over, it is not poisonous, and an ounce of it has been 
given to animals without doing any harm, though 
three grains of white phosphorus have proved fatal. 

Red phosphorus may be used in the manufacture 
of matches, but they will not strike when rubbed on 
a rough surface ; they require to be rubbed on a 
specially prepared surface containing substances rich 
in oxygen. The best method is to make the heads of 

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Industrial Diseases 

the matches of potassium chlorate and potassium 
chromate, which contain much oxygen, and the red 
phosphorus is contained in the brownish surface 
on the box. These matches, therefore, contain no 
phosphorus of any kind ; they are known as "safety 
matches." 

The most striking result of poisoning by white 
phosphorus is necrosis, or death of the bone of the 
jaw. This condition, which is popularly known as 
u phossy jaw/' is the direct result of the poison acting 
through a decayed tooth, for it seems practically 
certain that it does not occur if all the teeth are 
sound. Another peculiar effect of chronic phosphorus 
poisoning amongst match-makers is an increased 
brittleness of the limb-bones, so that they break from 
very slight causes ; fortunately this complication is 
very rarely seen. 

It is clear that the risks attending the manufacture 
of matches from white phosphorus are sufficiently 
great to make it necessary that the manufacture 
should be regulated, and the improvement of ventila- 
tion of the workroom, and careful attention to the 
teeth, are the most important points. 

In France, where the manufacture of matches is a 
State monopoly, the claims for compensation by 
workmen suffering from necrosis of the jaw and other 
manifestations of phosphorus poisoning became so 
great, that experiments were made to discover a 
substitute. After several failures a compound of 
phosphorus, the sesquisulphide, was tried, and it has 
proved a success. It appears to be very little poison- 
ous, if at all, and it is almost free from odour. It 
also has the merit that it will strike anywhere. The 
problem, therefore, of the provision of a non-poisonous 

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Industrial Diseases 

match that will strike anywhere has been solved, 
but it cannot quite be maintained that the solution is 
completely satisfactory, for French matches are far 
from good. 

Other attempts have been made to find a non- 
poisonous match which will strike anywhere. The 
manufacture of safety matches from red phosphorus 
will no doubt increase, but it is not likely that they 
will ever replace the other form. The demand at 
present is for a match that will strike anywhere, and 
that demand will be supplied. At the beginning of 
191 1 it became illegal in the British Isles to employ 
white phosphorus in the manufacture of matches, and 
if this law is enforced "phossy jaw " and the other 
results of phosphorus poisoning should disappear. 

Brassfounders' Ague 

Since 1862 it has been recognised that workers in 
brassfoundries are very liable to have a peculiar form 
of disease, to which the name of u brassfounders' 
ague " is given. The disease affects only those who 
are new to the work or who return to work after 
an interval of two weeks or more. A few hours 
after the man has started work he becomes languid 
and feels very cold. His face is pale and covered 
with a cold perspiration, he shivers and his teeth 
chatter. He has to take to his bed, and after vomit- 
ing he is able to sleep ; when he awakes, he is well. 
Brass consists of copper and zinc, and when brass 
is melted dense clouds of white smoke arise, and de- 
posit a white powder which is oxide of zinc. The 
disease has nothing to do with ague, and even clini- 
cally the resemblance is only very slight. It is 
certainly due somehow to the brass, but there is no 
unanimity as to which of the two metals, copper or 

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Industrial Diseases 

zinc, is responsible for it. There is something to be 
said on both sides, and it is possible that the attack 
is due to the action of both metals. 

Milk is the best preventive of brassfounders' ague, 
and this fact was discovered by the workmen them- 
selves; it is useful also in the treatment of the 
condition. 

Writers' Palsy 

In 1832 Sir Charles Bell first described the affection 
which is now known as " writers' palsy." The disease 
affects most commonly those people, such as clerks, 
who earn their living by writing, but it is doubtful 
if the writing is the sole cause, because it does not 
always attack those who write the most. Tobacco 
and alcohol in excess and worry of all kinds favour 
its appearance. The condition is curious. There is 
no real lack of power, for the patient can usually 
paint or draw as well as before, but the muscles con- 
cerned in writing are suddenly thrown into a state 
of spasm as soon as any attempt is made to write. 
The prevention is more important than the cure. 
The less the movements in writing are confined to 
the fingers the better ; the whole arm should move. 
Typewriting is a useful substitute, as in it entirely 
different muscles are employed. For the patient with 
writers' palsy to insist on continuing his work is 
very unwise, for his condition will grow worse. Tele- 
graphists' cramp also occurs, but it is less commonly 
seen now than formerly, for learners are encouraged to 
use both hands. Early treatment is very successful ; 
after a few months' rest, recovery always follows. 

Cramp or spasm also occurs in other occupations, 
such as piano playing — in fact in any work in which 
excessive action of any muscles is required. 

257 R 



CHAPTER XXVI 
LEGAL MEDICINE 

The Recognition of Blood Stain 

At many points medicine comes in contact with law. 
Every citizen who is liable to serve on a jury may 
at any time be called upon to give a verdict in a case 
in which the medical evidence is the most important 
that is brought against the accused, and he will be in 
a better position to judge of the weight to be given to 
the evidence if he knows something of the general 
principles of the methods employed by medical men 
to elucidate the truth. 

Blood Stains. — Every one thinks he is able to recog- 
nise a blood stain when he sees it, and it might be 
thought to be a very easy matter to say whether 
certain marks on clothing or furniture or weapons 
were or were not due to blood. Experience, how- 
ever, has shown that there may be great difficulty in 
arriving at a certain conclusion on this matter. The 
more recent the blood the more easy is it to express 
a decided opinion, for most people would be able to 
speak accurately about blood marks while they are 
still wet, but blood undergoes changes rapidly, and 
its recognition soon becomes difficult. When the 
material on which the stain is found is white, recog- 
nition is easier than if the material is dark. A few 

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detached spots on a rusty knife might easily give a 
wrong impression. Therefore, unless the blood is 
very recent and is obviously blood, the evidence of 
those who are not specially acquainted with the 
subject should not be given much weight on the 
question whether the stains are due to blood or not. 

Yet even in a recent stain it is desirable that a 
careful scientific examination be made, for it has 
happened that some dye has been mistaken for blood. 
When a stain is recent, the technical examination of it 
is fairly simple, for the blood corpuscles will not have 
been destroyed, and therefore it will be possible to see 
them and to examine them. A blood stain on any 
object will dissolve readily in water, and this is the 
first step in deciding whether the stain is blood ; for 
many stains — rust, for instance — will not dissolve in 
water. The best solution to use for the purpose of 
dissolving the blood stain is composed of one part of 
glycerine to seven parts of water. When the stain is 
on leather, care has to be taken not to dissolve out 
the tannin from the leather, for that will form an 
insoluble compound with the blood-colouring matter, 
and this is also true of oak or any other wood con- 
taining tannin. A little of the stain is dissolved and 
then it is examined under the microscope, and the 
blood corpuscles can be seen, and it is possible, 
sometimes, to give an opinion as to the group of 
animals from which the blood has come. I will deal 
more fully with this question a little later, when I 
discuss whether it is possible to distinguish human 
blood from that of the lower animals. 

The discovery of the red corpuscles proves with 
absolute certainty that the liquid which produced the 
stain was blood. When the stain is a little older the 

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red corpuscles will have disappeared. They have 
become destroyed by the drying, but they have left 
behind them their colouring matter, and it is by this 
colouring matter that it is possible to recognise 
whether the stains are the stains of blood. As the 
blood stains get older they soon lose their reddish 
colour, and become darker and browner in tint, until 
they may be almost black. When they are on iron 
or steel weapons or objects they are very likely to be 
mixed with rust marks, and then it becomes still more 
difficult to distinguish them from rust. It is possible 
to separate the blood from the rust by means of the 
water and glycerine solution already mentioned, for 
the blood will dissolve, while the rust will not, and 
nitration will give a clear solution of the blood. 

The colouring matter of blood as it exists in the 
body, and for a short time after it has been shed, is 
called haemoglobin, and this can be obtained in a 
crystalline form which is characteristic, so that the 
crystals will prove that the liquid causing the stain 
was blood. The stain must be very recent in order 
that it shall be possible for haemoglobin crystals to 
be obtained from it. Much more commonly, when 
the time has come for an examination of a stain which 
may be blood, it is so old that it is no longer possible 
to obtain the crystals of haemoglobin, for it has broken 
up. It is in these circumstances necessary to employ 
another chemical test. By the addition of a little 
acetic acid and a minute quantity of sodium chloride 
or common salt and the application of heat some 
minute crystals will be formed. Their colour may 
vary from a faint yellowish red to a dark brownish 
black ; and they are of a definite shape, and they are 
technically described as oblique rhombic prisms. 

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Legal Medicine 



These crystals are crystals of u haemin," and they can 
be readily identified under the microscope. A further 
test corroborating the opinion that these are crystals 
of haemin can be applied by adding a minute drop of 
hydrogen peroxide, and immediately small bubbles of 
gas will be given off from each crystal. The haemin 
test is perfectly conclusive of the presence of blood, 
and it is applicable to a blood stain however old it 
may be. 

Day's test may also be applied. This is to be per- 
formed as follows : A drop or two of tincture of 
guaiacum is added to the solution of the stain, and 
then a few drops of ozonic ether are poured on to the 
top of the liquid, and a blue colour will soon appear 
where the two liquids touch. This is an extremely 
delicate test, for there is no coloured substance other 
than haemoglobin or substances derived from it which 
will give this reaction. 

Perhaps the most striking proof of the presence of 
blood is afforded by the spectroscope. It will be 
necessary to give a short account of this instrument. 
When light is allowed to pass through a prism, it is 
broken up into its constituent colours, and we have, in 
place of the white light, a series of tints passing from 
red at one end through yellow and blue to violet at 
the other end of the spectrum. When sunlight is 
the light employed it is seen at once that many small 
dark bands pass across the spectrum, and it is found 
that in sunlight these dark bands are always in the 
same relative positions, and we know that they corre- 
spond to certain chemical substances, and their pre- 
sence in sunlight proves to us that these chemical 
substances exist in the sun. For instance, in the 
yellow part of the spectrum is a very definite dark 

261 



Legal Medicine 



band which proves the presence of sodium in the sun. 
These dark bands are useful in examining any 
spectrum, for they enable us to distinguish between 
two spectra which are very much alike. When we 
examine with a spectroscope any coloured liquid we 
find that every liquid has its own spectrum. When 
we examine blood we find a very definite spectrum, 
but it has several forms according to the condition of 
the colouring matter. Thus, if haemoglobin is present, 
and the blood is red as it is in the arteries of the body, 
a spectrum would be formed containing two broad 
dark bands just to the right of the sodium line ; if 
then we add a substance by which the oxygen is 
taken away, a single band replaces the other two. 
By readmitting oxygen to the blood the two bands 
reappear, and this transformation of the two bands 
into the single band and of the single band into the 
two bands can be repeated indefinitely. If the blood 
stain is older the spectroscopic test is differently 
applied, but the results are equally conclusive. 

There are certain substances which to some extent 
give spectra resembling those of blood, but they 
react differently to chemical substances, and there is 
no difficulty in distinguishing between them. The 
spectra of alkanet root and of madder in some re- 
spects bear a close resemblance to those of blood, but 
there is no difficulty in distinguishing between their 
spectra. 

The spectroscopic test is very trustworthy and very 
delicate, for it is said to be capable of detecting frnro- 
of a grain of haemoglobin, though if the amount of 
blood stain is very small, the test has to be applied 
with the aid of a microscope. 

As each of these three tests, the hsemin crystal 

262 



Legal Medicine 



test, the guaiacum test, and the spectroscopic test, 
is trustworthy in itself, it is obvious that if all three 
tests give a definite result there cannot be the very 
faintest doubt that the stain is the stain of blood. 

Supposing that the stain has been examined by all 
the tests that I have mentioned, or at least those 
which are applicable to the particular stain, and it has 
been decided with certainty that the stain has been 
produced by blood, the question then arises, Is it 
possible to speak with any certainty as to the source 
of the blood ? The question practically only con- 
cerns the blood of vertebrate animals, and of these 
there are five main groups. First there are the 
mammals to which man belongs, secondly there is the 
class of birds, thirdly the class of reptiles, fourthly 
amphibians, and fifthly fish. Now, the red corpuscles 
of these separate classes do differ in certain respects 
one from another. 

The mammalia possess red corpuscles which are 
round, and concave on each side ; and they possess 
no nucleus. Curiously, the members of the camel 
tribe are the only mammals which have oval red 
corpuscles, but they resemble other mammals in 
having no nucleus. In birds the red corpuscles are 
oval and bi-convex and they possess a nucleus : and 
the red corpuscles of reptiles and amphibians are also 
oval and are provided with a nucleus. In fish the 
corpuscles are round and nucleated. Thus, if the 
blood were sufficiently recent to show the red cor- 
puscles, it would be possible to say whether the blood 
was the blood of a mammal or not, and this micro- 
scopic test has been applied with success in the 
following case. 

A man maintained that he had coughed up some 

263 



Legal Medicine 



blood ; but when the blood was examined microscopi- 
cally it was at once seen that the red corpuscles in it 
were oval and nucleated, and therefore it could not 
be mammalian blood ; and later he acknowledged 
that the blood was obtained from a fowl. 

Sometimes the mere size of the corpuscle is suffi- 
cient to decide that the blood is not mammalian, for 
on the whole the amphibians have corpuscles which 
are much larger than those of mammalia. The frog's 
corpuscle is nearly three times as long as a human 
red corpuscle, and in one amphibian, the Amphiuma, 
the corpuscle is eleven times as long as a human red 
corpuscle, that is to say, it is about -^^ of an inch in 
length, and it is visible to the naked eye. 

We see, then, that it is possible, if the corpuscles of 
the blood can be obtained for examination, to decide 
whether those corpuscles belong to mammalian blood 
or not. 

The further question then arises : Supposing that 
we have identified the blood as derived from a 
mammalian animal, can we take a step further and 
say that the blood is certainly human ? 

The mammalian blood corpuscles differ in size. The 
largest appear to be those of the elephant, which 
measure about 2 ? 1 of an inch, while the smallest 
are those of the musk deer, 12 ^ 00 of an inch. The 
human red corpuscle measures a2 x 00 of an inch, but 
the size of the corpuscle does not appear to depend 
on the size of the animal, though the elephant happens 
to be one of the largest mammals and the musk deer 
is a small mammal. But the red corpuscle of a 
mouse is three times as big as that of the musk deer, 
though the mouse is a much smaller animal. In 
animals belonging to the same group, the size of the 

264 



Legal Medicine 

red corpuscle does vary somewhat with the size of the 
animal. On the whole it may be said that all the 
animals whose blood is likely to be confused with 
human blood, such as the horse, the ox, and the sheep, 
have red corpuscles which are smaller than those of man. 

Therefore if the corpuscles in a specimen of blood 
when examined were found to be definitely smaller 
than human red corpuscles the examiner would be 
justified in saying that in all probability the corpuscles 
were not human, but I do not think he would be 
justified in going further than this. For, though at- 
tempts have been made to establish the size of the 
corpuscles as a decisive test as to the nature of the 
source of the blood, the differences are so minute 
that it would not be fair to an accused person to let 
his fate be decided on this point. 

From time to time it has been suggested to utilise 
for the discrimination of the blood of one animal from 
another the fact that the crystals of haemoglobin do 
vary according to their source. The fact of the 
difference in the shapes of the crystals cannot be 
denied, and in certain cases the differences are so 
striking that a decision might confidently be based 
upon them. On the other hand, in certain cases the 
differences are extremely minute, and may depend 
on slight differences in the form of the crystals and 
the angle which one side makes with another. In 
the present stage of our knowledge at least, these 
differences must not be allowed to have much weight. 

Within the last few years it has been suggested 
to utilise "haemolysis" in the detection of the source 
of a specimen of blood. The method is a little com- 
plicated, but it may be stated briefly as follows : — 

If into the body of an animal, say of a rabbit, some 
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Legal Medicine 



human blood is injected, and after a short time a 
little of the blood of the rabbit is mixed with human 
blood, it is found to have the power of destroying 
the human red corpuscles ; they break up, and the 
liquid becomes transparent. This is "haemolysis." 
Thus if the blood of a rabbit which has been altered 
by human blood were mixed with a little unknown 
blood and it was found that the red corpuscles of 
the unknown blood were destroyed, there would be 
great probability that the unknown blood was human. 
The results, when the test has been applied experi- 
mentally, seem fairly trustworthy, but the subject is 
still entirely in an experimental stage, and therefore 
no great reliance can be placed on it, but it is possible 
that it may become of value in medico-legal matters 
in the future. 

To sum up ; first it is possible to detect blood and 
blood stains however old they may be, though the 
more recent they are the more easy a decision be- 
comes. Secondly, we can recognise the difference 
between mammalian blood and the blood of the 
lower animals provided that the blood has been shed 
sufficiently recently to enable the corpuscles to be 
examined. | Thirdly, it is not possible to identify with 
certainty the source of blood ; we cannot definitely 
say it is human, although from measurement of the 
red blood corpuscles and by other means we may 
form a fairly decided opinion as to their origin. 



266 



CHAPTER XXVII 
LEGAL MEDICINE (continued) 

Poisoning 

I have in the chapter on diseases of occupation dealt 
with a number of cases in which poisoning occurs in 
trades, and there I have also described a few instances 
in which it resulted from accident, but here I wish 
to speak especially of cases of poisoning not connected 
with occupation. Every now and then cases are 
tried in the law courts in which a person is accused 
of having given poison with intent to harm, and the 
decision will often turn on the medical evidence; and 
the members of the jury should be able to appreciate 
the nature of the medical evidence and to utilise it 
in arriving at a verdict. 

In the past there can be little doubt that charges 
of poisoning were made too frequently. Whenever 
death occurred suddenly without external violence, 
the most natural explanation appeared to be that 
it was due to the action of some poison administered 
with malicious intent. The rapid deaths which some- 
times occur in appendicitis or in perforated gastric 
ulcer may well have seemed to be the effect of 
poisoning at a time when the knowledge of medicine 
was much less than it is at present. 

Death may also occur with startling suddenness 
when it is caused by apoplexy or by disease of the 

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Legal Medicine 



heart, and if for any reason suspicion had fallen on 
any one, the rapidity of the death would be held to 
be a fact confirming the suspicion. When it was 
considered right to administer torture to get evidence, 
it was not difficult to obtain confessions as to the 
guilt of the suspected man, even though he was 
innocent. Even at the present day amongst savage 
races a sudden death is always regarded as the result 
of poisoning or witchcraft, and some one has to suffer 
for it. 

\It is certain that many have been executed for 
murders which had not been committed. This 
should make us careful not to be too ready to suspect 
poison, but on the other hand, it is very necessary 
that every sudden death, every obscure death, should 
be adequately investigated ; for many cases, even 
within recent years, have shown us that in deaths 
by poisoning no suspicion may arise for some time 
until some other circumstance may arouse it. 

Once suspicion has been aroused it is no difficult 
matter to detect a poison. There is a popular lidea 
that some poisons cannot be detected, and therefore 
those poisons are chosen by would-be murderers. 
This idea is wholly mistaken, for it can be said with 
certainty that every poison known to us can be de- 
tected by one means or another. This is true, not 
merely of an examination soon after death, but it is 
also true for nearly all poisons, even when months 
have elapsed, or even when the body has lain in the 
grave for years. 

I The resources of chemistry aud physiology are so 
great, that we have at our disposal means of identifica- 
tion which were absolutely unknown fifty years ago. 
The rarer alkaloids, such as aconitine, have been 

268 



Legal Medicine 



within recent years employed for homicidal purposes, 
but these substances can be identified with as much 
certainty as the commoner poisons, such as arsenic 
and antimony. 

In the Middle Ages poisoning was perhaps common, 
but even then deaths were ascribed to poison which 
were really due to natural causes. It is said that at 
one time poisoning was very commonly practised, 
especially in Italy, but much that was reported of the 
methods employed was absurd. Readers of Dumas' 
Monte Cristo may remember the description given by 
the Count of the method of preparation of a poison. 
A cabbage was watered with a solution of a poison, 
and three days later it was given to a rabbit which 
died shortly after ; a chicken fed on the body of the 
rabbit and it died also. In this manner it was 
suggested that the poisons of the Borgias were made, 
and it was thought that they could not be detected 
after death. That may have been true at that time, 
but it is certain that at present they could be recog- 
nised. There can be no doubt that there has been 
much exaggeration as to the abstruse methods that 
used to be adopted. 

It is very difficult to give an exact answer to the 
question, u What is a poison ? " The best definition 
appears to be, " A poison is anything which is capable 
of destroying life by chemical action on the tissues or 
by physiological action after absorption." This may 
be a little too wide, but at least it includes all the 
substances which are used for homicidal purposes. 

With regard to the sale of poisons, the law in 
England at present is hardly sufficiently strict. 
Schedules of poisons have been drawn up, and the 
poisons enumerated in them can only be sold with 

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certain restrictions. The package must bear a label 
on which is the name of the poison and also the 
word a poison." The most virulent of the poisons 
can only be sold to persons known to the seller or 
introduced to him by some one known to him, and 
the sale must be entered in a book kept for the 
purpose. These regulations apply even to " vermin 
killers/' and if fully carried out they would do much 
to prevent both intentional and accidental poisoning. 
Until recently crude carbolic acid was often sold in 
unlabelled bottles, and some parish authorities were 
even in the habit of giving it away for disinfecting 
purposes ; but, as the recipient provided the bottle, 
the carbolic acid was generally put into an ordinary 
wine or beer bottle, and it was often unlabelled. Cases 
of poisoning did arise from this cause. 

By the present law poisons intended for external 
use must be dispensed in special bottles, which can be 
recognised by the touch as different from ordinary 
medicine bottles. Much ingenuity has been expended 
in devising bottles which cannot be mistaken. 
Triangular bottles have been employed, and one or 
more of the surfaces have been roughened, so that 
the mere feel will at once indicate that it is not an 
ordinary bottle. One very ingenious form invented 
could only stand on the end at which was the cork, 
so that it was impossible to pour it out by mistake, 
but I do not think it came into use. 

Most of the accidental poisonings arise because 
people take up a bottle in the dark and pour out 
some of its contents into a glass and drink without 
seeing what they are taking. This should never be 
done, however certain one may be of the identity of 
the bottle. Some one else may have displaced the 

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bottle, and another may be in its place. Experience 
shows that many deaths are caused in this way. A 
man has been in the habit of taking some medicine 
frequently from a bottle always kept in the same 
place, and some day he picks up a bottle from that 
place and takes a dose from it, and not until he finds 
that it burns his mouth does he have the slightest 
suspicion that he has taken it from the wrong bottle. 
Sometimes, if these substances happen to be tasteless, 
the mistake may not be noticed until severe or even 
fatal symptoms come on. Among the poorer classes 
substances like spirits of salts (hydrochloric acid) 
or oil of vitriol (sulphuric acid) are often kept in wine 
or beer bottles. A child, seeing the bottle, will think 
that it contains beer, and will try to drink some, 
and, from fear of detection, he will drink a mouthful 
or more hurriedly, and, before he has time to notice 
the burning taste of the liquid, he has swallowed it. 
Many deaths occur in this way, and one great pre- 
ventive would be to take care that these dangerous 
substances are never kept in beer bottles, and they 
should not be put where children can reach them. 

The Mode of Action of Poisons 

Poisons do harm, either by their local action or 
by their action after they have been absorbed into 
the blood stream. The local action is seen in the 
effect of the strong acids and alkalies, such as 
sulphuric acid and caustic potash. These have a 
caustic effect on the tissues they touch ; if they are 
strong they destroy the tissues completely ; if they 
are weaker, they excite severe inflammation. The 
mouth usually is burnt, and the effect is also seen in 

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the gullet and the stomach. Sometimes it is possible 
to recognise which of these poisons has been em- 
ployed ; for instance, if the skin of the lips is turned 
yellow, nitric acid must have been used. Most often 
poisons exert their special action after they have 
been absorbed into the blood and have been carried 
about the body by the circulation. Thus, if opium 
be given, it has no action until it has entered the 
blood-vessels and been carried to the brain, which 
it affects with its special action. In a similar way, 
strychnine has no action until, after absorption, it 
has been carried to the spinal cord, where it irritates 
the nerve cells and causes the spasms which are the 
characteristic effect of strychnine. 

Antidotes 

An antidote is any substance which will counteract 
a poison. These are of several kinds, and they act 
in different ways. Some act mechanically y such as 
white of egg t olive oil, and demulcent fluids ; water 
also by diluting the poison will act in the same way, 
and similarly alcohol counteracts the effects of car- 
bolic acid. Some of these, such as white of egg, 
also act chemically ; as, for instance, where white of 
egg is given in a case of poisoning by corrosive subli- 
mate, it acts partly mechanically by protecting the 
wall of the stomach from the action of the irritant 
poison, and partly chemically by combining with the 
corrosive sublimate. It is related that Michael Faraday, 
when lecturing at the Royal Institution, had on his 
lecture table a glass of water and also a glass contain- 
ing a solution of corrosive sublimate. By an accident 
he drank some of the poisonous solution, but he 

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immediately perceived his mistake because of the 
burning taste of the liquid. At once he took a solu- 
tion of white of egg, which was fortunately at hand, 
and so he escaped any harm from the accident. 
The quantity he had taken was sufficient to prove 
fatal. 

Some antidotes act chemically ; that is to say, they 
neutralise the poison. If an acid has been taken, 
alkalies may be able to neutralise it, but it is obvious 
that the antidote must not be too strong, or it will 
itself do harm. Even plaster from the wall or ceiling 
has been used with success in cases of poisoning by 
acids, especially oxalic acid. Similarly, weak acids, 
such as vinegar, have been employed to neutralise 
caustic alkalies. 

The third way in which antidotes act is physiologi- 
cally. Thus one alkaloid is injected to neutralise the 
effects of another alkaloid. Physiological antidotes 
which work well in the laboratory do not always 
give equally satisfactory results when tried in cases of 
poisoning. 

When poisoning was, or at least was supposed to 
be, more common than it is at present attempts were 
made to devise a universal antidote against all poisons. 
Several of them were invented, and the most famous 
of these was " orvietan," which was made by Girolamo 
Ferrante of Orvieto, in Italy ; it was also called 
"Venice treacle," and it is mentioned in Scott's 
Kenilworth. 

When poison is taken, there are many circumstances 
which may modify its action. The quantity is, of 
course, the main factor determining the result ; and 
the greater the quantity the more severe are the 
symptoms. This is true of almost all poisons, but 

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when the poison is an emetic a small dose may be 
more dangerous than a large one, for the small dose 
will be retained while the larger dose will be vomited 
and the patient may recover. The more soluble a 
poison is, the more quickly it acts ; while, in the solid 
condition, its action is delayed. Habitual indulgence 
in a poison will in many cases give a partial immunity. 
Every one knows that this is true of tobacco and 
alcohol. Opium also has a similar effect, and doses 
can be taken after prolonged indulgence which would 
certainly kill a person unaccustomed to the drug. 
Children and infants, even though they are very easily 
affected by opium, may become habituated to it. 
Grainger reported that in the factory districts it was 
the custom to drug the children with laudanum ; the 
drugging began soon after birth, and ultimately a- 
child might be taking as much as fifteen or twenty 
drops of laudanum. 

Arsenic also appears capable of conferring on those 
who take it habitually an immunity against itself. 
Long ago it was reported that in Styria the peasants 
habitually take arsenic in quantities sufficient to poison 
any one else. Much doubt has been thrown on the 
correctness of these statements, and I am not satisfied 
that they are true. 

When a poison is administered immediately after 
a meal, its action manifests itself more slowly, and 
it is generally less violent than if it is given when the 
stomach is empty. 

In all cases of poisoning it must be borne in mind 
that idiosyncrasies to various substances are not 
rarely present. The possibility of the existence of 
an idiosyncrasy must always be remembered when 
symptoms of poisoning appear to arise from an 

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ordinary medicinal dose. I have dealt more fully 
with this matter in chapter xxviii. 

The onset of symptoms in a case of poisoning is 
generally sudden, occurring in a person previously 
perfectly well. It is often immediately after a meal 
or a dose of medicine. This occurs both in cases of 
acute and chronic poisoning ; and in chronic cases 
the coincidences are sometimes sufficiently striking 
to attract notice ; for instance, pain and vomiting may 
come on soon after any food or drink has been taken. 
In nearly all cases of poisoning the symptoms do not 
exactly correspond to any disease ; or the general 
condition of the patient is out of relation to the 
symptoms of which he complains. 

When symptoms of violent irritant poisoning arise 
after a meal, and especially when more than one 
person suffers from them, there is always the possi- 
bility that the cause is some decomposition product 
in the food and not what we ordinarily call poisons. 
In some of these cases in which the food has been 
" tinned," the toxic symptoms may be due to some 
of the metal forming the tin or the solder with which 
the tin was sealed. The chief metals proving danger- 
ous in this way are tin and lead, and the symptoms 
arc those resulting from poisoning by these metals. 
Quite apart, however, from the poisons of metallic 
origin it is certain that food sometimes, whether tinned 
or not, may give rise to serious symptoms closely 
resembling poisoning. 

When meat disagrees it is nearly always after it 
has been prepared in certain ways. "German sausage " 
may give rise to toxic symptoms, and especially if it 
is eaten raw or imperfectly cooked. These symptoms 
appear to be due mainly to a special bacillus, the 

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Bacillus botulinus. At Welbeck seventy-two persons 
were attacked after eating cold boiled ham, and four 
of the number died. In this case a bacillus was found, 
and it was probably responsible for the attacks. 

Veal pies have given rise to many cases of poisoning. 
In 1898, at Oldham, fifty- two persons were attacked 
after eating veal pies, and of these four died. In such 
cases the cause is probably a bacillus. 

On Good Friday 1882, at Inverness, over a hundred 
persons were taken ill after eating "hot cross buns," 
and when an inquiry was made into the outbreak, 
it was concluded that the cause was an irritant alka- 
loid probably derived from the spice used in making 
the buns. 

Honey, even when it is not adulterated, may some- 
times give rise to symptoms of poisoning. This is 
nearly always due to the fact that the bees have fed 
on poisonous flowers. It will be remembered that 
the ten thousand Greeks under Xenophon, when 
returning through Asia Minor, were attacked with 
some troublesome symptoms after eating honey. I 
have referred to this occurrence in the chapter on 
idiosyncrasies. 

Most epidemics due to milk are caused by the 
typhoid or diphtheria bacillus, but other attacks more 
of the nature of poisoning do occur. In 1899, at a 
school treat, sixty persons were attacked with severe 
symptoms of irritant poisoning, and the only food 
taken had been cake and milk; fortunately no fatal 
cases appeared. In 1901, in Glasgow, six hundred 
persons were attacked with symptoms of irritant 
poisoning, and the investigation proved that the attack 
was due to the milk of one dairy, and it was found 
that a cow, the milk of which was used on the day 

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of the outbreak, had died shortly after milking time. 
From cheese, ice cream, and milk a definite chemical 
poison has been isolated; it is called " tyrotoxicon," 
and it appears to be a product of the action of the 
butyric acid bacillus; it produces symptoms of irri- 
tation. 

All forms of fish may cause toxic symptoms, especi- 
ally if the fish is not perfectly fresh. From tinned 
fish, such as salmon, similar symptoms may occur, 
and death may sometimes follow. Lobsters, crabs, 
and shellfish, especially mussels, may also give rise 
to serious manifestations. The symptoms are gene- 
rally those of an irritant, and a nettle-rash may be 
produced. When the mussels have been scraped off 
a vessel, they seem especially harmful, and then may 
give rise to narcotic symptoms. A man who ate a 
large quantity of mussels scraped from the side of 
a vessel became absolutely unconscious, with very 
slow breathing, and he died some ten hours later. 

In many of the cases of illness from food, the 
cause is a micro-organism, but still there are many 
in which no microbe can be found ; in most of these 
there are discovered on analysis chemical substances 
to which the names of " ptomaines " or " cadaveric 
alkaloids " have been given. They resemble very 
closely the alkaloids found in plants, both chemically 
and physiologically. Many of these ptomaines are 
formed by decomposition, and are produced by the 
action of bacteria. Some other chemical substances 
of simpler composition are also found, and these are 
probably also poisonous. The conclusions to be 
drawn from the many cases which have been re- 
corded of illness and death following the eating of 
" tinned " food are, that if " tinned " foods are eaten, 

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only foods of good brands should be selected ; that any 
" blown " tins (that is to say, tins which are distended 
at each end from the formation of gas in the interior) 
should be destroyed ; that no tainted meat should 
ever be eaten ; and that all meat, whatever its source, 
should be well cooked. If these precautions were 
taken, the number of cases of poisoning from food 
would be much diminished. 

Closely allied to cases of poisoning are those in- 
stances in which irritant plants, such as the Primula 
obconica, give rise to irritation of the skin ; some 
animals also, such as the woolly caterpillars, and 
jellyfish, may give rise to very troublesome symptoms. 
• The bites and stings of insects may cause much 
irritation. A wasp sting on the tongue has proved 
fatal from the swelling to which it gives rise causing 
suffocation. A single wasp sting has proved fatal 
within fifteen minutes to a lady twenty-three years 
old ; death in this case was probably due to shock ; 
and another similar case has also been recorded. Bee- 
stings are sometimes productive of serious symptoms, 
but they are rarely fatal, though when a man has 
been stung by hundreds of bees death has resulted. 

Snake-bites in this country rarely case death, and 
even serious symptoms from the bite of the viper are 
not common. When they do occur it is generally in 
the summer, for then the venom is more powerful. 
Children suffer more than adults, because the dose is 
larger in proportion to the size of the body. 

It will not be necessary for me even to mention all 
the substances which have been or might be poisonous. 
It will suffice if I refer briefly to a few of the more 
important substances. 

The mineral acids, sulphuric, nitric, and hydro- 

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chloric acid, are much used for cleaning metals, both 
in trades and in domestic use, and therefore cases of 
accidental poisoning are not at all rare. The main 
method of prevention would be the exercise of care in 
the bottles in which the acids are kept, as mentioned 
above. Carbolic acid is so widely used for disinfect- 
ing purposes that cases of poisoning by it are not un- 
common ; fortunately it is now put in Schedule 2 of 
poisons. At present about ten per cent, of the deaths 
from poisons are due to carbolic acid. 

Borax and boracic acid are used so very extensively 
for preserving foods and milk, that is a matter of the 
greatest importance to consider what is the degree of 
toxicity of these two substances. No case appears 
ever to have been recorded in which death resulted 
from the internal use of borax or boracic acid in doses 
such as are customary for the preservation of food, 
or even in bigger doses ; so that no serious harm is 
likely to follow its use as a food preservative, if the 
quantity employed is really moderate. A danger, 
however, arises from the fact that when a perishable 
article of food, such as milk, passes through many 
hands, each person will in turn be inclined to add some 
food preservative, and thus the total amount contained 
'may easily be such as to cause illness. While it is diffi- 
cult to forbid entirely the use of borax and boracic 
acid, it seems to be desirable that the law should fix a 
limit to the percentage that should be present. 

Copper cooking vessels are probably not so common 
nowadays as they were at one time, and therefore 
copper poisoning is not now so common as it was. 
If the contents of a copper saucepan contain common 
salt or vinegar, or any acid substance such as rhubarb, 
or if any oily or fatty material be present, some of the 

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copper may get dissolved and may cause symptoms of 
poisoning. No such substances as these should there- 
fore ever be cooked in copper vessels. All copper 
vessels should be tinned, and care should be taken that 
the tin is not worn away. A case has been recorded in 
which several members of a family ate rhubarb which 
had been cooked in a copper saucepan ; it had been 
tinned but the tinning had been in parts worn away, 
and moreover the saucepan had not been well 
cleaned. They were all taken ill, and one died. 

In another way the possibility of poisoning by 
copper arises. It has long been customary to colour 
peas and other vegetables by means of copper salts, 
and some old cookery books advise that a penny 
should be placed in the saucepan, as it will improve 
the colour of vegetables ; or that they should be 
stirred with a copper spoon. The copper is added 
usually in the form of blue vitriol (copper sulphate), but 
it forms a green compound with the organic acids of 
the vegetables. It is probable that the quantity of 
copper used is so small that the amount taken at a 
single meal cannot do harm, but it is not unlikely that 
repeated doses of even a small amount might be 
injurious. It is very desirable that the coppering of 
preserved vegetables should be made illegal. 

The potato-blight is sometimes prevented by spray- 
ing the plants with a solution of bluestone. I know 
of no evidence that the potatoes are ever affected, or 
contain any of the poison, but one fatal case has been 
recorded in which a farm labourer employed in 
spraying the potatoes was poisoned, apparently by 
eating without washing his hands. 

Compounds of arsenic are used for several pur- 
poses, for washing sheep, for killing weeds, for fly- 

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papers, and for colouring wall papers. Eight 
members of a family were poisoned by arsenic by 
taking water for drinking purposes from a pail which 
had contained a sheep-dip. Four of the family died. 
By law arsenic, when sold in small quantities, must be 
mixed with soot or indigo, but there is little doubt 
that this regulation is often evaded. Poisoning by 
arsenic may certainly be caused by living in rooms 
the walls of which are papered with wall-paper con- 
taining arsenic. Although green papers are popularly 
supposed to be specially dangerous, papers of many 
tints may contain the poison. For a long time the 
manner in which the arsenic of the wall paper reached 
the occupiers of the room was unknown ; it was 
thought to be by dust. It has, however, been shown 
that several minute fungi live in the wall paper, and 
possess the power of decomposing the salts of arsenic, 
forming a gaseous compound, which is given off into 
the air of the room and then taken in with the breath 
by those living in the room. 

Many ores contain a small percentage of arsenic, 
and so it happens that a small quantity exists in many 
substances. Sulphuric acid frequently contains a 
little arsenic, and if this impure acid is used to make 
glucose, the product will contain some arsenic also. 
Glucose is much used in modern methods of manu- 
facturing beer, and as a result beer may contain 
arsenic. This was the source by which the arsenic 
gained access to the beer which gave rise in 1900 to 
the extensive Manchester epidemic of arsenical poison- 
ing, in which at least 6000 people were affected. As 
glucose is also employed for making confectionery, 
and as an adulterant of honey, arsenic may find its 
way into the body in many ways. 

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Poisoning by carbonic acid gas is not very 
common. It is the carbonic acid in the M choke- 
damp " which kills coal miners after an explosion. 
When men go down wells, or into brewers' vats to 
clean them out, and are rendered unconscious, the 
cause is carbonic acid. Limekilns also give off 
much of the gas, which may cause unconsciousness 
and death. 

It has generally been thought that the air of a well 
or vat is safe for breathing, if a candle will continue 
to burn in it. This has been shown not to be true 
by the following case. A girl carrying a candle 
entered a cellar in which grape juice was fermenting ; 
she was seized with giddiness and dropped the candle 
on to the floor, but she was able to run out of the 
cellar, and close the door ; then she fell unconscious 
on to the ground. When the door was opened the 
candle was found burning in the cellar. 

Carbonic oxide is a poisonous gas that must not 
be confused with carbonic acid. This gas is formed 
whenever organic matter is burned with an insufficient 
supply of air. The poisonous character of coal gas 
is largely due to the presence of carbonic oxide, and 
this is the reason why water gas is very poisonous, 
for it contains much of it. 

Even one per cent, of carbonic oxide gas in the 
air proves rapidly fatal to those breathing it. When 
death occurs from a leaking stove the death is due 
mainly to carbonic oxide, and closed anthracite or 
coke stoves should never be employed in bedrooms. 
Some cases have been recorded of death from the 
products of combustion of coke or charcoal, where 
there was no fire in the room. In one of these cases 
the fumes came from a stove burning charcoal in the 

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room above ; the fumes passed through an iron pipe 
into a flue, and then descended into the fireplace of 
the bed-room below, and there proved fatal. 

I do not intend to discuss the question whether 
alcohol is of value or not as an article of diet, but 
that it can act as a poison is beyond dispute. With 
the symptoms of ordinary drunkenness I need not 
deal. Acute alcoholic poisoning results from a very 
large dose of alcohol in a concentrated form, brandy 
or some other spirit commonly being the cause. A 
boy six years old died from three ounces of whisky ; 
a woman forty-one years of age died within six hours 
of drinking a pint and a half of whisky ; and a pint 
of spirit has proved fatal to a man in eight hours. 

Prussic acid is a very powerful poison ; it is some- 
times given intentionally. It is contained in the 
essential oil of bitter almonds, which is used to flavour 
confectionery, and which may contain a large percen- 
tage of prussic acid. 

Formerly the oil of bitter almonds proved fatal in 
a number of cases every year, but it is now a scheduled 
poison, and therefore it is not so easily obtained. 
Almond flavour is a weak solution of the oil. Prussic 
acid is contained in the kernels of cherries, and to 
a minute extent in the pips of apples and pears. 

In a trial where the prisoner was accused of killing 
by prussic acid, the defence was raised that the 
prussic acid found in the stomach was derived from 
the pips of some apples recently eaten. The defence 
failed. Nitrobenzene is an artificial product ; it has 
an odour resembling bitter almonds, and is used in 
perfumes and for flavouring pastry. It is very 
poisonous, for fifteen drops have proved fatal. A 
peculiar bluish appearance of the skin may be present, 

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and a similar result follows poisoning by aniline, 
which has gained entrance by being used in the 
manufacture of the shoes worn. 

There are many British plants which may prove 
fatal, especially to children, and the laburnum, the 
monkshood, the deadly nightshade, and toadstools 
deserve special mention. Children in elementary 
schools in the country might well be taught to re 
cognise the common poisonous plants of the district. 

Belladonna and aconite are common constituents 
of liniments, and they are liable to be taken in mis- 
take for medicines. Opium and its alkaloid morphine 
cause many deaths every year. Many patent medi- 
cines contain opium, especially those intended for the 
relief of coughs and pain ; it is also a constituent 
of some soothing syrups for children, and this is 
especially dangerous, because children do not stand 
opium well, and even one drop of laudanum has 
proved fatal when given to an infant seven days old. 
It is worthy of discussion whether any patent meBi- 
cine intended for the use of children should be 
allowed to contain opium. 



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CHAPTER XXVIII 

IDIOSYNCRASIES 

The old proverb that "One man's food is another 
man's poison " is based on a very large measure of 
truth. Substances which are perfectly harmless to 
one person, or even to the majority of the members 
of the human race, may produce dire results on a few 
people, and similar differences exist between different 
groups of animals. The nux vomica bean, which 
contains the very powerful poison strychnine, capable 
of killing all the higher animals, is liable to be attacked 
by a beetle which can feed on it, not only with 
impunity but even with benefit. An extract of bella- 
donna, or the deadly nightshade, which contains the 
virulent poison atropine, is often devoured by a 
minute mite which flourishes on this strange food. 
Goats are said to be able to eat the leaves of the 
aconite plant, which proves so poisonous to man and 
most animals, and yet to suffer no harm. From these 
instances (and many other similar cases could be 
quoted) we see that there are peculiarities in various 
groups of animals which render them immune to 
special poisons. Still more common, however, than 
this strange immunity is a tendency which is seen in 
individual members of groups of animals to differ 
from their fellows when brought into contact with 
some special substances. 

Our knowledge of these individual peculiarities is 

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ncrasies 



much more extensive with regard to members of the 
human race than with regard to any other class of 
animal. The instances are by no means rare. We 
often hear some one say that he cannot take quinine 
or some other drug because it produces an effect on 
him other than that which is produced on most 
people. It is possible that to some small extent 
imagination has a share in the production of these 
untoward results, but this will suffice to explain only 
a very few cases. Sea-sickness, for instance, is pro- 
duced in nearly every one when journeying on a 
rough sea for the first time, and some never lose their 
susceptibility, but there are a few fortunate indi- 
viduals who have never been upset in the slightest 
degree when at sea, however rough it may have been. 
This sensitiveness to the movement of a boat varies 
greatly in different people, and there is little doubt 
that the expectation of being sea-sick has no small 
share in the result. Every one has known of people 
who have suffered from sea-sickness even while the 
steamer was still on the smooth waters of a river. In 
such a case nothing but the expectation of sea- 
sickness could be responsible for the result. Many 
children and some adults suffer from train-sickness. 

Idiosyncrasies exist in regard both to medicine 
and to food. As a rule nearly all drugs are fairly 
uniform in their action, and if any drug gives rise 
frequently to unexpected results, it may be taken as 
almost certain that that drug varies in composition. 
Yet even with drugs which are uniform in chemical 
nature, variations of the effects may certainly occur. 
Most of the powerful drugs have been found at one 
time or another to affect excessively persons who 
have been treated with them, and it is remarkable 

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how great is the regularity with which in these 
persons the harmful effects follow even small doses of 
the substance. It is said that opium, which in most 
people produces a sedative, quieting effect, has been 
known to give rise to convulsions similar to those 
which would follow the administration of an ex- 
cessive dose of strychnine, and many of these cases 
are so carefully recorded that we can have no doubt 
that they are true. Quinine, when given in small 
doses, usually causes few symptoms — perhaps there 
may be a slight headache — but sometimes it causes 
eruptions of various kinds. Belladonna may occa- 
sionally, even when merely applied externally in the 
form of a plaster, give rise to symptoms of mental 
disturbance. Potassium bromide, when given to 
most people, causes no change in the skin, but it 
may, even in moderate doses, give rise to several 
very striking forms of skin eruptions ; and this is true 
also of potassium iodide. These anomalous effects 
produced by drugs are certainly remarkable, but still 
more striking are those analogous disturbances which 
are caused by certain articles of food. It is indeed 
strange that there is hardly any form of food used 
which has not at some time or another given rise to 
harmful symptoms. I am not speaking here of effects 
due to decomposition having taken place in the food 
by the growth of a micro-organism which may have 
produced some poisonous substance, but to the effect 
arising from the taking of food in a good and satisfac- 
tory condition. When food has undergone decompo- 
sition it affects, as a rule, all who partake of it, though 
even here we find differences not to be accounted 
for by the varying quantities of food which have been 
taken. When the harmful symptoms are due to the 

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peculiarity of the person who partakes of the food, 
we find that others can eat of it without suffering any 
ill effects. Especially remarkable is the fact of the 
uniformity with which the effects are produced in 
the same person. Not long ago, a boy about fourteen 
years old said that he was unable to take oatmeal 
porridge as it made his face swell. A little natural 
scepticism was felt as to the truth of his statement, 
and the boy was persuaded to eat some porridge 
under observation. Before the meal was finished, 
the skin of the boy's face was seen to begin to swell, 
and within twenty minutes of the commencement of 
the meal the face was so swollen that he was unable 
to see out of one eye. Many persons complain of 
feeling discomfort after eating porridge ; irritation of 
the skin not unfrequently occurs, but I am not aware 
of any other case in which such marked results 
followed as in the case of the boy I have mentioned. 
It is especially remarkable in these cases of food 
poisoning, that the harmful effects are seen even 
when the susceptible person is not aware that he has 
had that special kind of food. 

Rice is a substance which has on many occasions 
been known to produce harmful effects ; it must not 
be forgotten that rice is especially prone to decom- 
position, and many consider that beri-beri is some- 
how associated with decomposed rice. But I am not 
referring to such cases as these ; there are people 
who suffer after having eaten rice even in very small 
quantities. In one case shortness of breath always 
followed the taking of rice, even in the smallest 
quantities. A lady who suffered in this way com- 
plained one day of severe breathlessness after taking 
some soup, and she said that she felt sure she had had 

288 



Idiosy 



ncrasies 



some rice. It was found on investigation that the 
soup had been thickened with a little rice flour. In 
another case in which rice always gave rise to attacks 
of shortness of breath the sufferer was especially 
careful to avoid any article of food which was likely 
to contain rice. One day he had a severe attack of 
shortness of breath after drinking some bottled beer, 
but for some time he could not discover how any rice 
could have got into the beer. At last he discovered 
that, as the beer had become flat, some grains of rice 
had been introduced in order to excite fresh fer- 
mentation. 

Honey is especially liable to cause unexpected 
symptoms. This is no doubt due in part to the pre- 
sence of some unusual constituent obtained from some 
poisonous plant. Readers of Xenophon's Anabasis 
will remember the description of the severe attacks of 
illness from which the u Ten Thousand" suffered 
after eating honey in the Colchian Hills. It has been 
suggested that the honey of this district owed its 
peculiar properties to the fact that the bees had fed 
on a species of rhododendron (Ponticus). The 
curious flavour of Australian honey is said to be due 
to the eucalyptus tree. It is, however, unlikely that 
the serious symptoms which occurred in the following 
case can be ascribed to any unusual constituent. 
A man found that whenever he took honey he always 
suffered from swelling of the tongue, frothing of the 
mouth, and blueness of the fingers, and these symptoms 
followed whatever the source of the honey, though 
it was noticed that they were more severe when the 
honey was eaten in the comb. It has long been 
known and widely recognised that fish are specially 
prone to produce harmful symptoms, and these are 

289 T 



Idiosy 



ncrasies 



seen more particularly with some fish than with 
others. The mackerel is very likely to give rise to 
serious symptoms, and in most cases this is associated 
with decomposition changes. Still, sufficient cases 
have been recorded which seem to show that in- 
dividual peculiarities exist in some persons which 
render them specially liable to be affected by this 
article of food. 

We have seen above that the quantity of the special 
article of food required to cause severe symptoms 
may be in some cases extremely small, but it is 
almost impossible to estimate how very minute the 
quantity needed may be. Eggs have a very harmful 
effect on many people, and sometimes merely the 
quantity necessary for glazing a roll or a bun has 
been sufficient to evoke severe symptoms. In most 
of these cases of egg-poisoning the sufferers complain 
of soreness of the throat, and abdominal pain and 
vomiting. Even the external application of the white 
of egg may irritate the skin. There is some evidence 
that with care some of the patients with these peculi- 
arities can be cured, by accustoming them at first 
to very minute doses of the poisonous substance ; 
but the evidence of cure is up to the present not 
very strong. 

Even more remarkable instances of idiosyncrasy 
have been recorded. Sir Kenelm Digby has related 
that if a rose were laid on the cheek of a certain 
lady while she was asleep the cheek was blistered, 
and " rose cold " is, if not so common as hay fever, 
at least as troublesome when it occurs. Hay fever, 
too, attacks only a small percentage of those exposed 
to the cause, which certainly appears to be the pollen 
of the hay. Cases have been recorded where the 

290 



Idiosyncrasies 



sight or smell of pork was sufficient to cause faintness. 
As Shakespeare said, H Some men there are, love not 
a gaping pig ; some that are mad, if they behold a 
cat." We have no clue to such idiosyncrasies as 
these. They are not merely the result of imagination, 
for the exciting cause generally acts perfectly well 
even when its presence is unknown to the sufferer. 
That idiosyncrasies of all kinds exist, there can be 
no doubt, and as soon as recognised they have 
to be taken into account both in diagnosis and in 
treatment. 



291 



CHAPTER XXIX 

TREATMENT BY X-RAYS, BY RADIUM, 
AND BY FINSEN LIGHT 

I have described in the chapter on Instruments for 
Diagnosis the general arrangement of the apparatus 
needed for the production of X-rays, and it will be 
unnecessary to repeat here the account, for in all 
essentials the apparatus employed is the same. 

Very soon after the publication by Rontgen of his 
discovery it was found that the X-rays were capable 
of affecting the skin and other tissues of those who 
were exposed to them ; and these harmful effects I 
will speak more about after I have described the 
beneficial effects of treatment with the rays. 

When it was seen that the X-rays were powerful 
enough to lead to the destruction of healthy tissues, 
it was thought probable that they might be able to 
exert a similar influence on diseased tissue, therefore 
the rays were soon tried in various diseased conditions. 

It took a long time before those employing X-rays 
became capable of utilising them to the greatest 
extent, for it was difficult to determine the correct 
amount. Many attempts were made to measure the 
rays, and at first these attempts depended on the 
strength of the primary current and the size of the 
spark gap, or even the strength of the secondary 
circuit ; but all these proved to be fallacious tests. 
Sabouraud was the first to introduce accuracy into 

292 



Treatment by X-rays 

the matter, for he showed how the X-rays might be 
measured with a fair amount of accuracy. His 
method consisted in exposing to the rays a " pastille," 
composed of a cyanide of barium and potassium. 
This substance undergoes a definite change of tint 
after exposure to a certain quantity of the rays, and 
when the colour of the pastille has attained a certain 
standard tint, the required amount has been attained ; 
in fact the method employed is that adopted by 
photographers for measuring the amount of exposure 
that should be given to a photographic plate. 

Whatever amount of X-rays be administered, there 
is always an interval between the exposure to the 
rays and the first appearance of symptoms, and this 
is called the " latent period." The latent period may 
be as short as a week ; this is only in cases in which 
a large dose of the rays has been given ; or the latent 
period may be as long as three weeks, when a small 
dose of the rays has been administered. In each case 
that dose of the rays is chosen which experience has 
shown to be the most suitable for producing the effects 
desired. 

Many diseases have been treated by means of the 
X-rays, but at present those which seem to be the 
best suited for this method of treatment are not very 
numerous. They are chiefly affections of the skin. 
Lupus responds very well to the action of the X-rays, 
and as a large area can be treated at one time this 
treatment is especially suitable for those extensive 
cases which under the Finsen light would require a 
very long treatment, for by the Finsen light only 
a very small area can be treated at one time. The 
results after X-rays for lupus are not always so good 
in appearance as after the Finsen light. 

293 



Treatment by X-rays 

There is a very superficial form of cancer which is 
known as rodent ulcer ; it usually occurs on the face, 
and it is very suitable for treatment by the X-rays ; 
the results are generally very good. 

In the last few years, the X-rays have been employed 
with great success in the treatment of ringworm of 
the head. With ordinary methods of treatment ring- 
worm of the scalp is usually a very intractable disease 
even though great care be taken, while if the treat- 
ment is carried out carelessly by the patient or his 
friends, as is only too commonly the case among the 
poorer classes, it may last for several years. The 
main difficulty in the treatment is due to the fact 
that the microbe which is the cause of the disease 
invades the little pocket, or " hair follicle," in which 
the hair lies, and we know of no way in which anti- 
septics can be made to pass down to the germs so as 
to kill them. It was found by Sabouraud of Paris 
that when the X-rays are applied to the scalp in the 
correct dose, the hair will after two or three weeks 
fall out completely, and with the hairs will come out 
all the germs causing the disease, so that the hair 
follicles are left free from the germs. By this method 
it must be distinctly understood that the X-rays do 
not act as an antiseptic, for it is doubtful if they have 
any antiseptic action, but the rays merely serve to 
remove completely the hairs from their follicles, and in 
this way, too, all the germs are removed. The correct 
dose is measured by means of a Sabouraud's " pastille." 
The hair falls out in about three weeks, and after a 
few weeks more the new hairs begin to appear, and 
these new hairs are free from germs. With care no 
harm results, and the duration of the disease is very 
much shortened. At the Ringworm School of the 

294 




A Safety Caiinbt i or X-ray Operators 



Tlie frequent use of X-rays may be attended with the gravest danger to the operator, 
but this is eliminated by placing the patient in a special cabinet lined with lead ami 

iron. The windows are of lead uli-^ which is impervious to the rays. The rays are 
controlled from the out-id-.-. The child is being treated for ringworm. 



Treatment by X-rays 

Metropolitan Asylums Board the cure of a case of 
ringworm of the scalp before the introduction of the 
X-ray treatment used to take on an average one year 
and nrne months. Since the X-ray treatment has been 
employed the average duration of the stay of a child 
in the schools has been reduced to about four 
months. 

A determined effort is now being made by the 
London School Authority to extirpate ringworm 
from London, and it may well be that in a few years 
the disease may become rare. 

The question often arises whether any danger is 
likely to result from the use of X-rays in treatment. 
When the rays had been only recently introduced 
they were used without any precautions, for their 
harmful effects were not known, and a few patients 
suffered from them, but much more often the sufferer 
was the operator, for he was exposed, not only on 
one or two or a few occasions to the rays but for 
hundreds of times, and unfortunately several of the 
operators have died as the result of the injuries caused 
by the rays. Now, however, precautions are regu- 
larly taken, and the operator is careful not to expose 
himself to the direct course of the rays, and he wears 
gloves which will not allow the rays to pass through 
to his hands. From our present knowledge of the 
rays it can confidently be asserted that no harm 
will result to a patient from the rays during the ex- 
posure necessary for examination of a part by means 
of the screen or for the taking of the skiagram, and 
with treatment also no harm will follow if the ordinary 
precautions are observed. 

It has been suggested that using the X-rays for 
the cure of ringworm may lead to lack of develop- 

295 



Treatment by Radium 

ment of the tender brains of young children. In 
answer to this it may be said that we have no evi- 
dence supporting this view — in fact all the evidence 
points in the opposite direction ; and Sabouraud, who 
has now had seven years' experience of his method, is 
able to state definitely that children thus treated are 
as intelligent as other children who have not been 
submitted to the influence of the rays. 

In conclusion it may be said that the X-rays form 
a powerful weapon, capable of doing much good 
when employed with care, capable also of doing 
harm if used carelessly : but this may equally be 
said of many other methods employed in medicine 
and surgery, and it is quite certain that with due care 
the X-rays will bring nothing but good. 

Radium 

Not long after Rontgen's discovery of the rays 
which are called by his name, Becquerel, while in- 
vestigating some salts of uranium, found that they 
gave out rays which were able to produce feeble 
photographic effects, even after passing through bodies 
opaque to light. Compounds of thorium were found 
to possess similar properties. At first it was thought 
that the power was connected with the uranium itself, 
for the metal was more active than any of its com- 
pounds ; but further investigation showed that some 
minerals containing uranium, especially pitch-blende 
and chalcolite, were more active even than uranium 
itself, and from these minerals radium was separated 
by Mme. Curie by a prolonged research in which the 
constituents of pitch-blende were tested separately. 
Other radio-active metals have been recognised, but 

296 



Treatment by Radium 

radium remains the best known and the most used of 
them all. 

The cost of radium is very great, and there are 
two reasons for this : one is that the minerals con- 
taining it are not very widely distributed, and the 
second reason is that even in those minerals in which 
it exists to the greatest extent it is present in only a 
very minute percentage. The mine from which the 
first supplies of pitch-blende were obtained is situ- 
ated at Joachimstal near Carlsbad, but mines occur 
in this country in Cornwall, and the demand for 
radium has resulted in attempts being made to work 
pitch-blende in several other parts of the world. 

Radium is allied chemically to barium and thorium, 
and its amount in any ore bears a constant ratio to 
the amount of uranium present ; that is, the amount 
of radium .is about one-millionth part of the amount 
of uranium. A ton of the pitch-blende from the mine 
at Joachimstal will yield about two grains and a half 
of radium. 

Radium is always giving off heat, so that its tempera- 
ture is always two or three degrees Fahrenheit above 
that of the surrounding air ; and an idea of the 
amount of heat given off may be gathered from the 
statement that it is sufficient every hour to melt its 
own weight of ice. 

Radium is continuously giving off an " emanation," 
and also it sends out " rays." The u emanation " is a 
gas, which is luminous ; it can be condensed to a 
liquid by means of cold ; and it possesses the power 
of making " radio-active " any objects in its neighbour- 
hood. The "emanation" is continuously giving off 
a large quantity of heat. The "rays" are of several 
kinds, and they have been named Alpha, Beta, and 

297 



Treatment by Radium 

Gamma rays. They all possess the power of acting 
on photographic plates, like X-rays, and they can 
make substances like barium cyanide become phos- 
phorescent. 

The Alpha rays consist of minute particles charged 
with positive electricity, travelling at a speed of some 
twenty thousand miles a second. They can pass 
through opaque objects to a certain extent, but it does 
not take much to stop them ; a plate of aluminium 
only one-five-hundredth part of an inch in thickness 
is sufficient to block them completely. 

The Beta rays are composed of particles negatively 
electrified ; they are very much smaller than the Alpha 
rays, probably only one-thousandth part of the size, 
but they travel fifty times as fast. They have much 
more penetrating power, somewhere about a hundred 
times as much, for they can pass through a plate of 
aluminium one-fifth of an inch thick. 

The Gamma rays are not electrified, and they travel 
at a velocity equal to that of light. They can pass 
through a plate of aluminium twenty inches thick. It 
appears that the Gamma rays are identical with, or at 
least indistinguishable from, the Rontgen rays. 

As radium is continuously emitting the emanation 
and these rays it is continuously losing weight, so that 
ultimately a piece of radium bromide would dis- 
appear, but the rate of disintegration is extremely slow, 
and it has been calculated that the life of a portion of 
radium is some 1200 years or more. 

Inasmuch as radium is continuously being broken 
up, one of two conclusions must follow. Either there 
was formerly a very much larger quantity of radium 
in the world than at present, or radium is continuously 
being formed. It seems now certain that radium is, 

298 



Treatment by Radium 

on the one hand, being formed continuously, and on 
the other it is continuously breaking up ; and there 
is reason to think that uranium is the substance which, 
by undergoing a change, gives rise to radium. 



The Applications of Radium in Medicine 

It was early recognised that radium was capable 
by means of the rays it emitted of producing effects 
similar to those obtained by the use of the Rontgen 
apparatus, but the first indication that the rays of 
radium were capable of affecting the human body 
was afforded by an unintentional experiment per- 
formed by Curie. He travelled for some hours having 
a fairly large amount of radium in a tube in his 
pocket, and a few weeks later he discovered a sore on 
his side opposite the place where the tube of radium 
had been. It took, however, some little time for him 
to recognise the connection between the two facts. 
When it was seen that radium could affect healthy 
skin very much in the same way as Rontgen rays, its 
action was tried on various diseased conditions of 
which I shall speak later. 

Experience has shown that the Alpha rays have 
very small penetrating power, for they are hardly 
able to pass through the skin, but they are liable to 
cause much irritation. The Beta rays can pass 
through a greater thickness of tissue, but the Gamma 
rays, which are probably identical with X-rays, have 
the greatest penetrative powers. The proportions of 
the rays vary greatly, and it has been estimated that 
unscreened radium, i.e. radium not surrounded by any 
metal screen, gives off 90 per cent, of Alpha rays, 
9 per cent, of Beta rays, and only 1 per cent, of 

299 



Treatment by Radium 

Gamma rays. When surrounded by a thin metal 
screen the proportions will be greatly altered, so 
that barely i per cent, of Alpha rays, 90 per cent, 
of Beta rays, and 9 per cent, of Gamma rays will 
be emitted ; while if a lead screen is used all the 
Alpha rays will be blocked, and only 10 per cent, 
of the Beta rays and 90 per cent, of Gamma rays 
will pass through. Therefore by using metallic plates 
of greater or less thickness it is possible to "filter 
the rays/' so as to obtain those which are specially 
desired. 

Radium can cause inflammation of the skin or even 
ulceration if the application is sufficiently prolonged. 
If tadpoles are exposed to the influence of radium, 
they cease to grow, and seeds when exposed will 
cease to sprout, but radium has very little power 
over bacteria. 

The duration of the application of radium will 
necessarily vary with the strength of the preparation ; 
and the screen usually used with it will differ accord- 
ing to the action required. If a superficial effect 
is desired, then the radium may be used unscreened, 
but if it is wished to eliminate the superficial action, 
screens must be introduced, sufficient to block out 
the Alpha rays and part of the Beta rays. As to 
the use of radium in treatment, it may be said that 
in the first place various superficial conditions of 
the skin yield to radium, such as birth-marks or 
"port-wine stains" and hairy or pigmented moles. 
Chronic eczema and overgrown scars also are amen- 
able to treatment with radium. Further, some of the 
more superficial forms of cancer, such as "rodent 
ulcer," can be cured by radium, and even in the more 
deeply seated forms of cancer, good is sometimes 

300 



Treatment by Finsen Light 

done, but it is too early yet to speak with any certainty 
on this point. Sometimes neuralgia has yielded to 
treatment with radium. 

It has been said that good has resulted from the 
injection of the radium "emanation" in a case of 
cancer in a mouse, but I am not aware that any such 
success has been met with in malignant disease in 
the human being. It is worthy of note that many 
natural mineral waters, such as those of Bath, contain 
radio-active substances, and it is possible that some 
of the beneficial effects produced by these waters 
may be due to their radio-activity. 

Finsen Light 

That rays of light can affect beneficially the health 
of the body has been known for ages. Improvement 
in the general health follows life in the open air, 
and this is in some part at least attributable to the 
effect of the light of the sun. The bleached and 
unhealthy appearance of plants which have been 
grown in the dark is an exemplification of the im- 
portance of light. In the chapter on Germs I have 
referred to the fact that the rays of the sun have a 
very definitely harmful effect on most forms of 
microbes that cause disease, and in this way also 
light is beneficial. It was not, however, until com- 
paratively recently that the light of the sun was 
put to any therapeutic use. 

Finsen of Copenhagen employed the rays of the 
sun for the treatment of lupus ; the patients were 
placed in the open air and the rays of the sun were 
concentrated on the affected spot by means of a 
large lens, while the interposition of a glass u trough " 

301 




Treatment by Finsen Light 

containing a special liquid served to exclude the 
greater part of the heat rays. The results were very 
good. The patches healed rapidly, and the scar was 
smooth and unnoticeable. The light of the sun, 
however, is in most climates only occasionally avail- 
able, and the ultra-violet or actinic rays on which 
the remedial effect depends are present in a very 
small proportion during the winter months. Finsen 
therefore decided to try the effects of a very strong 
electric arc lamp. The light of the arc lamp contains 
many actinic rays, and it must be sharply distin- 
guished from the ordinary incandescent electric lamp 
which is used in private houses, for the light of the 
latter contains hardly any actinic rays : so that the 
incandescent lamp is useless for the purpose of 
treatment. 

The light from the arc lamp is conducted to the 
part to be treated and concentrated on it by means 
of quartz lenses, for quartz does not obstruct the 
actinic rays to the same extent as glass. Further, if 
the maximum effect is desired, it is necessary to com- 
press the part with a quartz lens in order to empty 
the blood-vessels of the blood, and when the part is 
thus rendered free from blood, the rays can penetrate 
more deeply. To obviate the heating effects the piece 
of quartz used to compress the parts is often made 
double, and a current of water is allowed to circulate 
in the space between them. 

The Finsen lamp is very effective in most cases of 
lupus, and it is especially valuable in the more super- 
ficial forms. Unfortunately it is not possible to treat 
a large area at one time ; a patch of skin about the 
size of a shilling is all that can be treated at once, 
and as each area requires from five to twenty ex- 

302 



; - 




Treatment by Radium 



There may be a great future for radium ; at present its use is mainly restricted to 
various skin conditions, such as birth-marks, and superficial cancers. The radium is 
simply applied to the part by means of a small holder for a short time. Radium is 
one of the most costly substances known, and only a small quantity is employed ; but 
it is not u?ed up in any way, and so it lasts indefinitely. 



Treatment by Carbonic Acid Snow 

posures, and each of these lasts some twenty minutes, 
it is clear that Finsen treatment is somewhat slow ; 
but so far as the appearance and results are con- 
cerned, it cannot be surpassed. 

The Finsen lamp is a very large and expensive 
instrument, and many smaller arc lamps have been 
constructed, which give satisfactory results, though in 
some cases the duration of exposure needs to be 
increased. 

There are a few other skin diseases in which light 
treatment appears to be of value, but it is especially 
useful for lupus, and when used in this disease the 
results are all that can be desired. 



Carbonic Acid Snow 

It is convenient to describe the use of solid car- 
bonic acid here, though it is not allied to the radiant 
forms of treatment. 

While the cautery has been in use for many cen- 
turies as a remedial agent, it is only within the last 
few years that high degrees of cold have been 
employed in the treatment of disease. Repeatedly 
freezing a part by means of ethyl chloride spray has 
given good results in some cases of lupus, but it has 
never been widely adopted, and the effect is slow 
because the degree of cold is not great. Solid 
carbonic acid, or " carbonic acid snow," as it is 
often called, is a very convenient method of applying 
intense cold. To put the matter simply, it may be 
said that the temperature of solid carbonic acid is 
just as much below the temperature of ice as the 
temperature of ice is below that of boiling water. 
The "snow" is very easily obtained. In all large 

303 



Treatment by Carbonic Acid Snow 

towns carbonic acid gas is used for making effer- 
vescent mineral waters, and for this purpose it can be 
bought compressed in strong steel cylinders. The 
pressure in these cylinders is so great that the gas is 
condensed to a liquid. When the tap of a cylinder is 
turned and the gas is allowed to escape slowly, it 
comes out as gas, but if the gas is allowed to escape 
rapidly it absorbs heat so quickly in becoming gaseous, 
that part of it is converted into the solid form, looking 
very much like snow. This can be collected and 
formed by compression into a rod about the size of a 
lead pencil, and with this rod of solid carbonic acid 
snow diseased tissues can be treated. 

When the pencil is pressed on the affected part it 
is rapidly frozen ; sometimes the application lasts 
only five or ten seconds, sometimes it may last a 
minute, and the effect produced depends in part on 
the duration of the application and in part on the 
amount of pressure exerted. When the pencil is 
removed the part remains hard and white for a few 
seconds and then it thaws. The application of the 
pencil causes very little pain, but as it thaws it hurts 
a little and for a few days afterwards it may be sore. 
If the application has been slight, very little effect 
may follow ; with a stronger application the super- 
ficial tissues are destroyed, and if necessary even 
deeper effects may be produced. The cases most 
suited for this treatment are naevi, warts, lupus, rodent 
ulcer, and " port-wine marks." 

This method is at present new, and sufficient time 
has not yet elapsed to fix with any exactness the class 
of cases most suitable for treatment. One point, 
however, deserves special mention. The appearance 
of the skin after treatment is extremely good ; the scar 

3°4 



Treatment by Carbonic Acid Snow 

is so soft and supple that it is hardly distinguishable 
from healthy skin. 

An even greater degree of cold than that produced 
by solid carbonic acid is available, and that is afforded 
by liquid air. It produces its effect much more 
rapidly, and it gives very satisfactory results, but it is 
not, as yet, a commercial substance, and therefore it 
is only used to a very small extent. 



305 U 



CHAPTER XXX 

MALINGERING 

From time to time persons are found who endeavour 
to deceive others by imitating the signs of disease, 
and this fraud is called malingering. It has existed 
from very early times, and it has always been difficult 
to detect. In Shakespeare's play, the Second Part of 
Henry VL, the Duke of Gloster detects the fraud of 
Simcox, who claimed to have been cured of blindness 
by visiting the shrine of St. Alban. Gloster showed 
that Simcox had never been blind by asking him the 
colour of various objects, and in every case he named 
the colours correctly, which could not be possible if 
he had been cured only immediately before. Then 
Gloster convicts Simcox of fraud in simulating lame- 
ness, for when he is asked how he became lame he 
says that it was from climbing into a tree for plums 
when he was a youth ; this was hardly possible if he 
had been born blind. Further, the lameness dis- 
appears rapidly after one stroke from the whip of 
the beadle. Malingering is as common as ever at the 
present time, and much care and skill are required to 
detect it ; but the increase of our knowledge enables 
us to recognise it in cases which at one time would 
have been considered genuine. 

There are many motives which impel persons to 
simulate the manifestations of disease. To beggars 
who can appear to possess diseases likely to excite 

306 



Malingering 



the sympathy of the passer-by, the rewards of pro- 
ficiency may be very great. Every one will remember 
Sir Conan Doyle's story of The Man with the 
Twisted Lip, in which is told the tale of a man 
who, when at home, led a life of respectability, but 
he became, during his working hours, a professional 
beggar in the City of London, with a curious mal- 
formation of his lip. Whether this individual's tale 
was founded on fact or not, it is certain that a great 
many professional beggars earn comfortable liveli- 
hoods by putting on the signs of disease. Paralysis 
is one of the most money-bringing maladies, for the 
passer-by, feeling the difference between his own 
strength and power of walking and the pitiable con- 
dition of the paralysed beggar, gives readily ; and if 
the site has been wisely chosen, the pecuniary results 
may be very much more than would be expected. 

Internal pains, however much the supposed sufferer 
groans, do not prove so remunerative as some form 
of disease that is visible to others, and it is very 
fatiguing to groan for long so that all who pass 
by may hear. If a person in the street is supposed 
to be suffering from acute pains, those who see him 
are more ready to take him to the hospital than to 
give him money, but that would hardly suit the 
professional beggar. I have been told that in the 
East End of London it is possible to buy pieces of 
adhesive plaster on which have been painted sores of 
various kinds. One of these is placed on the body or 
limb of the poor sufferer, so as just to be visible to 
the kind-hearted. It says much for the good-hearted- 
ness of the British public that a large number of 
healthy people reap the reward of their deceit and live 
comfortably on it. 

307 



Malingering 





Fits also pay well. They are generally epileptiform 
in character, and if an epileptic fit comes on in some 
public place, it has time to pass off before the patient 
is taken to a hospital, and many coins find their way 
into the patient's hand. Fits as a rule are, however, 
overdone, and it is true generally that most malingerers 
are inclined to overdo the symptoms. They either 
have too many symptoms or they have them in such 
a very severe form that if the symptoms were genuine 
the patients would soon die. Some beggars who have 
had opportunities of observing fits or other forms of 
disease for months or years become very expert, and 
may for a short time deceive even medical men, but their 
success is always short-lived if they are submitted to 
a careful medical examination. The frothing at the 
mouth, which is a well-known sign of an epileptic fit, 
is generally managed by the aid of a piece of soap 
concealed in the mouth, but the unconsciousness 
which is absolute in real epilepsy cannot stand, in 
these imitation fits, the infliction of a sharp pain. 

Malingering is frequently seen in countries where 
military service is compulsory, the object of the 
malingerers being to render themselves ineligible for 
service, but even in countries where voluntary service 
exists many who enlist endeavour to obtain their 
discharge by simulating an attack of some malady. 

Sometimes these unwilling soldiers have inflicted 
real injuries on themselves in order to escape service, 
and although this can hardly be called malingering 
it is very closely allied to it. At one time it was 
necessary for the soldier, before he could load his 
musket, to bite off the end of the cartridge. In those 
days it was not uncommon for a man to have one 
or more teeth extracted or filed down so as to obtain 

308 



Malingering 



exemption, or if he had already entered the service 
he would have "an accident," and one of his front 
teeth would be knocked out, so that he was no longer 
able to bite off the end of the cartridge. Sometimes 
also the trigger finger has been chopped off with the 
same intention. There is a tale which is told of a 
very determined attempt to escape service. A soldier 
became suddenly attacked with paralysis of the right 
arm. No cause could be found for it and the paraly- 
sis appeared to be complete, and even when he was 
awakened suddenly in the middle of the night, still 
the arm did not move. All the efforts of those 
surgeons who examined him were expended in vain 
to prove him to be a malingerer. For malingering 
was suspected, but no proof could be obtained. 
Ultimately, after several months of examination spent 
in vain, he was given his discharge, and he left the 
town on the top of a stage coach. Many of his 
comrades had come to see him off, and as the coach 
drove away he waved a last farewell with his para- 
lysed arm. 

Once a man simulated blindness. He was care- 
fully examined, but nothing wrong was to be seen 
in his eyes even after the most careful examination, 
and though the doctors were practically certain the 
man was a malingerer, they could not prove it. At 
last they thought they would have a decisive test ; he 
was placed near the edge of a pier and told to walk 
straight forward. He took several steps and then 
fell into the water, for he knew well that those re- 
sponsible for the test could not let him drown. 
Later, when he had obtained his discharge, his eye- 
sight wonderfully returned to him. Another man 
with paralysis of one arm was able to use both arms 

309 



Malingering 



in swimming as soon as he was thrown into the 
water. A very interesting case, known some years 
ago to many connected with hospitals in London, 
was a man who had a true paralysis of the left arm, 
and weakness of the left leg, the result of a former 
attack of apoplexy. He had been in hospital, where 
he had been very comfortable, and as the paralysis 
of his arm prevented him doing any work, he was 
always much more happy in the hospital than out 
of it. Therefore, whenever he wished to be received 
into a hospital, it was his habit to go to an inn near 
the hospital of his choice. After he had been there 
a little while he would suddenly fall down apparently 
unconscious, and he would be carried into the re- 
ceiving room of the hospital. The medical officer 
who received him would immediately recognise the 
paralysis of one side, and from the age of the patient 
he would diagnose some form of apoplexy and would 
receive him into a ward. After a few weeks some of 
the paralysis would pass off, but the arm would not 
regain its power. Then, when all the improvement 
had occurred that seemed likely, he would be sent 
to a convalescent home. There are many general 
hospitals in London, and he visited most of these in 
turn, and each visit gave him about three months' 
rest. Unfortunately for him, however, though the 
number of hospitals in London is large, it is not 
unlimited, and therefore after a few years he was 
compelled to return to a hospital he had already 
visited, and on more than one occasion he was recog- 
nised by some one who had known him before. 

It is always possible to detect malingering if the 
examination be sufficiently prolonged. Often the 
symptoms are not consistent with any known disease, 
and they may vary from day to day in a way which 

310 



Malingering 



does not occur in a real disease. A very useful 
method is to mention in the hearing of the patient 
that he has not some symptoms that he ought to 
have ; for instance, a physician may say that the hand 
should be more curved than it is, and in all proba- 
bility, when the patient is next seen, the hand will 
be more curved than it was before. The use of an 
anaesthetic solves many difficult problems, and will 
sometimes enable a definite opinion to be expressed 
in a case of malingering. 

It is very easy in many ways for a malingerer to 
produce eruptions and sores on the skin by rubbing 
or applying acids. A very common method is to dip 
a penny in vinegar and to bind it firmly on the arm. 
If this is done daily for a few days a very definite 
ulcer will result. Matches dipped in water and rubbed 
on the skin will also produce sore places, but all these 
attempts are easily detected by those accustomed to 
skin diseases. 

Compensation for injuries is a prolific source of 
simulation. When a railway accident occurs, it is 
not very rare for some one who has not been hurt 
at all, or has received only a slight injury, to pretend 
that he has received internal injuries sufficiently 
severe to prevent him working. In railway accidents 
such injuries certainly do occur, though no outside 
signs of injury are present, for sometimes patients 
who have been suspected of malingering have died 
as the result of their injuries ; but it is equally certain 
that many of those who bring claims against the 
railway companies are malingering. The present 
method of paying a sum down for cases where there 
is no visible proof of injury certainly favours malinger- 
ing, for some of these cases have recovered rapidly 
soon after the money has been paid. Doubtless 

3ii 



Malingering 

occasionally this recovery has been assisted by the 
relief from worry which adequate compensation 
would give to a genuine sufferer, but in many cases 
the recovery occurs because there was no disease 
before. In all cases of real doubt the fairest method 
both to the company and to the patient seems to be 
for the court to order an annual payment so long 
as the disability shall continue. 

Colour blindness is sometimes simulated ; but it is 
easy to detect, for most of the attempts are made by 
men who have vague ideas as to the nature of the 
condition. There are tints which appear almost 
identical to ordinary eyes, but to colour-blind eyes 
they are very different. Another method that is em- 
ployed is to put over the malingerer's eyes spectacles 
containing tinted glasses. 

In this and many other cases the great widening of 
modern medical knowledge renders it possible to 
detect fraud that would have passed unscathed 
through all the tests in the past. 

Sometimes it has happened that the attempt to imi- 
tatedisease has been only too successful, and permanent 
serious injury, and even death itself, has followed. 
Many years ago a man started an ulcer in his leg 
by means of a copper coin soaked in vinegar. His 
general health was not good, and the inflammation he 
had started spread rapidly. Gangrene of the leg 
followed, and amputation had to be performed. It is 
marvellous what trouble malingerers will take to 
accomplish their ends, and though it is probable that 
in a small proportion of these cases there is some 
mental aberration, it is certain that in the vast majority 
of malingerers personal gain is the sole motive of the 
deception. 

312 



CHAPTER XXXI 

THE MEDICINE OF THE FUTURE 

In the preceding pages I have given a brief account 
of what medicine was in the past, and I have 
also described to some extent the medicine of the 
present day. I have mentioned some of the diffi- 
culties which have been encountered in the progress 
of medicine, and I have told how some of those 
difficulties have been overcome ; how year by year 
and century by century advances have been made. 
At some epochs the advances have been great and 
striking, but far more commonly progress has been 
made by small and almost imperceptible steps, and 
only those who have looked at the practice of medicine 
with a broad view have been able to recognise the 
progress that has occurred. For many years the 
authority of the ancient masters of medicine tended 
to retard the advance of the science ; respect for 
those who had done so much for medicine tended 
to restrain their successors from deviating too widely 
or too suddenly from what had been taught so long 
before. But in spite of this, and in spite of the 
then want of knowledge of anatomy and physiology, 
medicine and surgery steadily made their way onward. 
From time to time they may have strayed into by- 
paths which led nowhere, but this was never for 
long. The innate love of truth, the desire to find 
the best methods of treatment and the true origin 

313 



The Medicine of the Future 

of disease, have always dominated the medical 
mind. 

Within the last century the progress has been 
phenomenal ; more advance has been made during 
that period of time than in many centuries preceding 
it, and more progress still will be made in the future 
than in the past or present. They of the past have 
done much ; the present has done still more ; but we 
look forward with hope and confidence to the future 
to solve many problems and to remove many diffi- 
culties which trouble us at present. Only those who 
know truly how much has been done in the past 
and can be done in the present can appreciate fully 
what the future has in store for us. By considering 
the weather of past years, by studying the laws of 
meteorology, it is possible for us to foretell, to a 
certain extent, the weather that is to come. So, too, 
with medicine. When we look upon what our pre- 
decessors have done with their scanty knowledge of 
those sciences, anatomy and physiology, on which 
true medicine must rest, when we regard what is being 
done at the present day with our very thorough study 
of all the sciences ancillary to medicine, we may have 
good hope for the future. With a much fuller know- 
ledge of anatomy and physiology than we possess 
even now, with a wider appreciation of the truths 
of animal chemistry, with a more thorough knowledge 
of the ways and powers of the many micro-organisms 
which attack the human body, we may feel sure that 
in the future the science of medicine will rise to 
heights almost incomprehensible to us of to-day. We 
can be certain that in the future our difficulties will 
be cleared away, our hardest problems will be solved. 

At one time those who were working for the ad- 

314 



The Medicine of the Future 

vance of medicine were few in number ; now, however, 
the spread of civilisation has added greatly to the 
fighting forces of medical science. In the past the 
spread of Greek learning to the Arabs did much to 
advance medicine ; so in the present day the spread 
of knowledge to many parts of the world has added 
largely to the number of those who are studying to 
promote the progress of the science of healing. Not 
only the countries of Europe, but Canada and the 
United States of America and the countries of South 
America, are producing men who are earnestly de- 
voting themselves to the task of adding to our know- 
ledge of the remedial art, and those sciences on which 
it depends. In our own time to the list of civilised 
and scientific nations has been added Japan. So that 
to-day in many parts of the world medical science 
is being cultivated to an extent never known before. 
To every country medicine has been indebted. In 
England we find Harvey discovering the circulation 
of the blood ; to America we owe the discovery of 
surgical anaesthesia; to Koch of Berlin we are indebted 
for the discovery of the bacillus of tuberculosis ; 
to Pasteur of France for the germ theory of fermen- 
tation ; to Lister in Scotland we owe antiseptic 
surgery ; to Kitasato of Japan we are indebted for 
the discovery of the bacillus of plague. Each country 
furnishes its quota for the fighting force. The 
scientific men of all nations are as one in their 
furtherance of science and truth ; science knows no 
political boundaries, and the sincere follower of 
science is, so far as his science is concerned, a true 
cosmopolitan. 

What, then, of the medicine and surgery that are to 
come ? In the first place we shall know far more 

315 



The Medicine of the Future 

than we do at present of the causation of disease. 
We shall learn that there are factors in the production 
of morbid conditions which are unknown to us at 
present, and that there are modes of action, even of 
forces now well known to us, of which we do not 
dream. It would be useless to enumerate the many 
unsolved mysteries as to the mode of origin of disease. 
The history of past progress in medicine has only too 
often told us how far from the truth have been our 
guesses as to the way in which diseases arise. 

In the chapter on Malaria I have described the 
results of the observations of careful physicians before 
the true etiology of that disease was discovered, and 
from our present superior knowledge we can see how 
far from the truth were their guesses, and on what 
erroneous lines their surmises proceeded. So will it 
be with the causes of those diseases as yet unknown 
to us. When those who come after us learn the 
true etiology they will feel inclined to smile at the 
guesses and theories we are now propounding. When 
the truth is learned much that appears incompre- 
hensible to us will become perfectly clear, and apparent 
inconsistencies will be explained. 

To take only one instance. At the present time we 
have no certain knowledge of the cause of cancer. 
Theories there are many, but facts there are few, and 
certainty there is none. With an increased know- 
ledge of the causes of this disease will doubtless come 
an increased power of treatment, and this scourge 
will in due time be removed from us. 

Will new diseases arise ? It is difficult to be sure 
that new microbic diseases will appear, but the 
chances are greatly in favour of it. At all events it 
is certain that diseases hitherto unknown will be 

316 



The Medicine of the Future 

described, as occurs at present. It may be that some 
diseases have not been recognised as separate diseases 
previously, and they may have been confused with 
some other more common affection ; but be the ex- " 
planation what it may, we may feel quite certain that 
in the future, as in the past, new maladies will receive 
recognition. 

Certainly in the class of diseases due to occupations 
new diseases must arise, for new conditions will exist, 
and will give rise to new affections. In the chapter 
on the Diseases of Occupations I have already referred 
to " caisson disease," which occurs in workmen who 
labour in the highly compressed air in caissons in the 
beds of rivers. This is an entirely new disease, and 
it could not arise until the conditions causing it were 
present, and it is only within the last few years that 
men have had to work under a great increase of 
atmospheric pressure. In deep mines there is some 
increase of pressure of the air, but that is nothing 
compared to the increase met with in some caisson 
work. So in the future new conditions will arise. 
So also the electric injuries, occurring only too 
commonly nowadays, are new to medical science. 
The very increase in our knowledge of nature will 
add to the diseases from which man will suffer. The 
burns caused by the X-rays and by radium could not 
occur until the advance of science had put in our 
hands the powers that X-rays and radium possess. 
The very luxuries due to the increase of civilisation 
add also to the number of diseases. The evils re- 
sulting from alcohol and tobacco could not be known 
until alcohol and tobacco were employed. 

In these tatter days perhaps the greatest evil re- 
sulting from an ever-increasing civilisation depends 

317 




The Medicine of the Future 

on the growth of drug habits. In place of the opium 
and Indian hemp which sufficed our predecessors, we 
have now in this last century a long list of drugs from 
morphia to cocaine, and from cocaine to chloral, and 
it is but too certain that in the time to come the 
advance of chemical knowledge will add numerous 
drugs to the list. It may well be that some may think 
that the benefits accruing from the science of medicine 
are dearly bought at the price of an increase in the 
means of producing disease, but with this opinion I 
cannot agree. The fault lies not with the science 
which produces these drugs, for every one of them 
has a beneficial use, but with the men who misuse 
them and put to a harmful purpose that which was 
meant to help the human race. Those, however, who 
have the most belief in the beneficent function of 
medical science look forward not so much to a time 
when all the ills that flesh is heir to can be remedied 
by the skill of the physician, but to a time when the 
science of medicine will have advanced so far as to be 
able to prevent the occurrence of these maladies. It is 
a noble aim to strive to cure our suffering brethren, to 
put an end to the pain which has arisen sometimes 
through faults of their own, sometimes through the 
action of others, and sometimes through the laws 
of Nature which they have disobeyed. Yet it is 
far greater to strive to prevent these diseases before 
they appear, and that is the role of the medicine of 
the future. The study of hygiene or preventive 
medicine has made great advances. By an accurate 
appreciation of the causes giving rise to disease it is 
now possible to prevent many maladies which were 
at one time looked upon as inevitable or as the result 
of the wrath of the gods. 

318 



The Medicine of the Future 

With the greater knowledge of the causes of disease 
which time will bring us, there will be put into 
the hands of the physician of the future a weapon 
far more powerful than any we can wield to-day. 
We may reasonably look forward to the time when 
many of the evils which afflict us now will be avoid- 
able, and as a result the span of the life of man, 
which even in our own time has extended beyond 
what it was a hundred years ago, will be stretched 
several decades beyond the three score years and ten 
that at one time were allotted to man. Yet, to attain 
such results as these there will be stringent conditions. 
On the willingness of the individual to accept the 
teachings of the science of those days, to obey the 
dictates of the medicine of the future, will depend the 
reward which science will then offer. 

Even in those far-off days there will be some who 
prefer the gratification of the moment to the health 
of the future ; who disregard the teachings of science 
because they do not apply to the immediate present. 
To such as these Nature will still reply as she replies 
to-day to those who break her laws, whether un- 
wittingly or of malice aforethought, that they shall 
surely die. To these medicine can only offer what is 
second best — not the prevention of disease, but its 
treatment, more or less efficacious as the breach of 
the laws of Nature has been less or more pro- 
nounced. 



Printed by Ballantvnb, Hanson &> Co. 
Edinburgh &* London 



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